Columbia  ©ntoergtt  p  \<\t>c 

Hbrifjool  erf  Bental  anb  #ral  burger? 


Reference  Htbrarp 


Plate  13. 


Gummatous  ulceration  of  the  right  calf  (Mracek). 


LUh.  Anst  F.  Reichhc 


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A  MANUAL 


SYPHILIS 


AND    THE 


VENEREAL  DISEASES 


BY 

JAMES    NEVINS    HYDE,  A.M.,  M.D. 

Professor  of  Skin,  Genito-Urinary,  and  Venerea]  Diseases,  Rush  Medical  College,  Chicago; 

Dermatologist  to  the  Presbyterian,  Michael  Reese,  and  Augustana  Hospitals,  of 

Chicago  ;  Consulting  Dermatologist  to  the  Chicago  Hospital  for  Women 

and  Children  and  to  the  Chicago  Orphan  Asylum 


FRANK   HUGH    MONTGOMERY,   M.D. 

Associate  Professor  of  Skin,  Genito-Urinary,  and  Venereal  Diseases,  Rush  Medical 

College,  Chicago;  Professor  of  Skin  and  Venereal  Diseases,  Chicago  Clinical 

School;   Dermatologist  to  St.  Elizabeth's  Hospital,  Chicago 


SECOND  EDITION,  REVISED  AND  ENLARGED 

With  58  Illustrations  in  the  Text,  and  19  full-page  Lithographic  Plates 


PHILADELPHIA 

W.  B.  SAUNDERS    &   COMPANY 

i  900 


2  7-22*3  76" 


Copyright,  1900,  by 
W.  B.  SAUNDERS  &  COMPANY. 


\qoo 


ELECTROTYPED     BY  PRESS    OF 

WESTCOTT    Sl    THOMSON.  W.    B.    SAUNDERS    &    COMPANY. 


PREFACE  TO  THE  SECOND  EDITION. 


In  the  present  edition  every  page  has  received  careful 
revision;  many  subjects,  notably  that  on  Gonorrhea, 
have  been  practically  rewritten,  and  much  new  material 
has  been  added  throughout  the .  book. 

With  a  view  to  better  illustration  of  the  subjects 
considered,  a  number  of  new  cuts  have  been  intro- 
duced, and  a  series  of  lithographic  plates,  which, 
through  the  courtesy  of  the  author  and  his  publishers 
have  been  taken  from  Mracek's  well  known  "Atlas  of 
Syphilis  and  the  Venereal   Diseases." 

The  authors  venture  to  hope  that  the  revision  will  be 
found  to  have  enhanced  the  practical  value  of  the  work, 
and  that  this  second  edition  will  meet  with  a  reception 
as  favorable  as  that  accorded  the  first  one. 


PREFACE. 


This  Manual  has  been  prepared  with  the  intent  of 
meeting  the  special  needs  of  the  student  and  of  the 
practitioner  rather  than  of  the  expert.  The  aim  has 
been  to  supply  in  a  compendious  form,  and  with  detail, 
all  practical  facts  connected  with  the  study  and  the 
treatment  of  syphilis  and  the  venereal  diseases.  Care 
has  been  taken  to  avoid  all  points  in  controversy  and  to 
exclude  the  data  which  are  to  be  sought  for  in  the  more 
voluminous  treatises  on  these  subjects. 

The  authors  are  glad  to  express  their  special  obliga- 
tions to  the  classical  works  of  Fournier,  Jullien,  and 
Mauriac ;  to  Keyes'  exceedingly  practical  treatise  on 
Genito-urinary  Diseases,  including  Syphilis  ;  to  Morrow's 
valuable  System  of  Genito-urinary  Diseases,  Sy philology, 
and  Dermatology,  in  three  volumes,  and  in  especial  to 
the  carefully  written  chapters  of  that  work  on  stricture 
of  the  urethra  and  syphilis  of  the  eye  and  ear.  The 
treatise  of  Bumstead  and  Taylor,  which  has  so  long  and 
so  well  represented  the  advance  of  knowledge  in  vene- 
real diseases,  has  frequently  been  consulted,  as  has  also 
the  standard  monograph  by  Finger  on  Blennorrhoe ,  and 
the  excellent  handbook  of  Messrs.  Culver  and  Hayden. 

The  authors  of  this  manual  are  also  gratified  in 
acknowledging  in  this  public  manner  their  appreciation 
of  the  courtesy  of  Messrs.  William  Wood  &  Co.  of 
New  York,  who  kindly  gave  permission  to  reproduce 
the  plates  originally  contributed  by  Dr.  Hyde  to  their 


10  PREFACE. 

Reference  Handbook  of  the  Medical  Sciences ;  to  Dr. 
Petrini  of  Galatz,  for  permission  to  reproduce  his  fine 
plate  showing  the  micro-organism  of  Ducrey ;  to  Dr. 
John  A.  Fordyce  of  New  York,  for  his  kindness  in 
supplying  the  micro-photograph  of  gonococci  which 
has  been  employed  as  one  of  the  illustrations ;  and  to 
Messrs.  Lea  Bros.  &  Co.  of  Philadelphia,  for  permis- 
sion to  make  use  of  one  of  their  original  cuts. 

The  authors  are  also  glad  to  express  their  acknowl- 
edgments to  Dr.  W.  F.  Robinson  for  his  efficient  aid 
while  these  pages  were  passing  through  the  press. 


CONTENTS. 


PAGE 

Introduction 17 

Syphilis 25 

Acquired  Syphilis 25 

Syphilis  of  the  Skin , 73 

Syphilitic  Affections  of  the  Hair        128 

Syphilitic  Affections  of  the  Nail 132 

Syphilis  of  the  Mouth  and  the  Tongue 136 

Syphilis  of  the  Respiratory  Tract      146 

Syphilis  of  the  Bones 152 

Syphilis  of  the  Larger  Joints 157 

Syphilis  of  the  Bursse      158 

Syphilis  of  the  Tendons  and  the  Tendinous  Sheaths  ......  159 

Syphilis  of  the  Aponeuroses 159 

Syphilis  of  the  Muscles 159 

Syphilis  of  the  Heart 160 

Syphilis  of  the  Blood-vessels 162 

Syphilis  of  the  Lungs 163 

Syphilis  of  the  Gastrointestinal  Tract 165 

Syphilis  of  the  Rectum  and  the  Anus .  167 

Syphilis  of  the  Genito-urinary  Organs 172 

Syphilis  of  the  Nervous  System 179 

Syphilis  of  the  Eye  and  the  Ocular  Appendages 186 

Syphilis  of  the  Ear      195 

Hereditary  Syphilis 196 

Treatment  of  Syphilis 221 

Acquired  Infantile  Syphilis 270 

Syphilis  in  Relation  with  the  Family  and  Society 271 

Chancroid 279 

Disorders  not  Invariably  Venereal 312 

Balanitis  and  Balano-posthitis 312 

Phimosis       315 

11 


12  CONTENTS. 

PAGE 

Paraphimosis 318 

"Venereal"  Warts 321 

Herpes  Progenitalis 2>2?> 

Hypochondriasis 326 

Acute  Urethritis 338 

Acute  Posterior  Urethritis 397 

Chronic  Urethritis 402 

Complications  of  Urethritis 442 

■    Epididymitis 442 

Prostatitis 45° 

-    Vesiculitis 467 

Cystitis 469 

Pyelitis 472 

Folliculitis 474 

Periurethritis 475 

Cowperitis 477 

Lymphangitis 478 

.    Adenitis 478 

Gonorrhoeal  Rheumatism 479 

Gonorrhceal  Conjunctivitis 487 

Ophthalmia  Neonatorum 495 

Gonorrhceal  Inflammation  of  the  Rectum  and  the  Mouth 497 

Stricture  of  the  Urethra 500 

Spasmodic  Stricture  of  the  Urethra 501 

Congenital  Stricture  of  the  Urethra 5°4 

Organic  Stricture  of  the  Urethra 5°7 

Instrumentation  of  the  Urethra 524 

Gonorrhoea  in  Women 575 


Index 5^3 


LIST   OF   ILLUSTRATIONS. 


FIGURES. 

FIG.  PAGE 

1.  Moist  papules  (after  Miller) 99 

2.  Large  pustular  syphiloderm  (after  Stelwagon) 104 

3.  Rupia  (after  Tilbury  Fox) 106 

4.  Resolutive  tubercular  syphiloderm  in  groups ill 

5.  Serpiginous  tubercular  syphiloderm  (after  Stelwagon) 114 

6.  Gummata  (after  Jullien) 118 

7.  Cicatrices  resulting  from  extensive  gummatous  infiltration  of  the 

face 121 

8.  Sabre-blade  deformity  of  the  tibise  in  hereditary  syphilis  ....  210 

9.  Hutchinson's  teeth  with  osteo-periostitis  and  ulceration  in  inherited 

syphilis 213 

10.  Hutchinson's  teeth 214 

11.  Phimosis  from  gonorrhoea  (Cullerier) 315 

12.  Paraphimosis  (Cullerier) 318 

13.  14.   Reduction  of  paraphimosis 320 

15.  Irrigation  nozzles 385 

16.  Valentine's  irrigating  apparatus 385 

17.  Kiefer's  urethral  irrigation  nozzle 386 

18.  Urethral  syringe 392 

19.  Pus  taken  from  an  old  case  of  gleet  with  a  recent  reinfection  .    .  414 

20.  Klotz's  endoscope 418 

21.  22.  Urethral  specula 418 

23.  Brown's  method  of  illuminating  the  urethra 419 

24.  W.  K.  Otis's  "  perfected  "  urethroscope 420 

25.  Koch's  tube,  for  use  with  Valentine's  urethroscope 420 

26.  Ultzmann's  syringe 430 

27.  Keyes's  double  taper  sound 434 

28.  Weiss's  sound 434 

29.  Winternitz's  psychrophor  (cooling  sound) 435 

30.  Keyes-Ultzmann  syringe  (Tiemann) 435 

13 


14  LIST   OF  ILLUSTRATIONS. 

FIG.  PAGE 

31.  Guyon's  deep  urethral  syringe 435 

32.  Annular  stricture  (Dittel) 508 

33.  Tortuou3  stricture  (Dittel)      509 

34.  The  normal  urethra  (Thompson)      ,    .  525 

35.  Van  Buren's  sound 525 

36.  37.  Sounding  of  the  urethra  (Keyes) 527 

38.  Sounding  of  the  urethra  (Keyes)      528 

39.  Sounding  of  the  urethra  (Keyes) 529 

40.  Relative  positions  of  triangular  ligament  and  bulb  of  urethra  (Cul- 

ver and  Hayden) 531 

41.  Handerson's  gauge 534 

42.  Bulbous  bougie 534 

43.  Elastic  web  bulbous  bougie 535 

44.  Otis's  urethrometer 535 

45.  Olivary  gum  bougie 535 

46.  Conical  bougie 536 

47.  Mercier  elbowed  catheter , 5^56 

48.  Gouley's  whalebone  bougies 536 

49.  Gouley's  catheter-staff 537 

50.  Beneque  sound 549 

51.  Gross's  modification  of  Civiale's  urethrotome 559 

52.  Otis's  dilating  urethrotome 561 

53.  Teevan's  modification  of  Maiconneuve's  urethrotome  with  guide  .  561 

54.  Teale's  gorget 563 

55.  Perineal  tube 564 

56.  Wheelhouse's  staff 566 

PLATES. 

PLATE 

1.  Initial  sclerosis  of  the  penis      Facing  page    30 

2.  Chancre  and  papillary  growths  of  the  tongue  (Hutch- 

inson)                 "  30 

3.  Pigmentary  syphiloderm  of  the  neck  and  shoulders 

(Mracek) "  82 

4.  Small  papular  syphiloderm  (Stelwagon) "  90 

5.  Papular  syphiloderm,  orbicular  grouping  (Mracek)  .             "  92 

6.  Papular  plantar  syphiloderm   (Mracek) "  96 

7.  Condylomata  of  the  ano-vulvar  region  (Mracek)  .    .             "  100 


LIST   OF  ILLUSTRATIONS. 


15 


8.  Pustular  syphiloderm  of  the  face  (Mracek)    . 

9.  Papulo-pustular  syphiloderm  (Mracek) 

10.  Pustulo-ulcerative  syphiloderm,  with  survival  of  scle- 

rosis of  the  penis 

11.  Pustulo-ulcerative  syphiloderm  in  a  cachectic  subject 

12.  Tuberculo-gummatous  infiltration  of   the    skin   with 

ulceration 

13.  Gummatous  ulceration  of  the   right  calf  (Mracek)  . 

14.  Gummatous    involvement    of    the    cervical    glands 

(Mracek) , 

15.  Syphilitic  paronychia  of  both  hands  (Mracek)  .    .    . 

16.  Mucous  patches  of  the  lips   (Mracek) 

17.  Syphilitic  disease  of  the  tongue  (Hutchinson)   .    .    . 

18.  Papulo-pustular    exanthem    of     hereditary     syphilis 

(Mracek) 

19.  Papulo-vesico-pustular  exanthem  of  the  plantar  region 

in  hereditary  syphilis  (Mracek) 

20.  Fig.   1.    Hutchinson's   teeth.      Fig.    2.    Bacillus    of 

Ducrey  (Petrini  de  Galatz) 

21.  Confluent  chanchroid  ulcers  of  the  skin  of  the  penis 

with  right  inguinal  adenopathy  (Mracek)    .    .    . 

22.  Micrococcus  gonorrhoeae  and  staphylococci  .... 


.  Facing  page  102 
"  104 


106 

106 

Il8 
120 

122 
132 

138 

142 

202 

204 

282 

284 
342 


SYPHILIS 


VENEREAL   DISEASES, 


INTRODUCTION. 


The  venereal  diseases  are  for  the  most  part  trans- 
mitted from  one  individual  to  another  in  the  contacts 
incident  to  the  relations  between  the  sexes.  The  day  is 
long  past,  however,  when  a  moral  stigma  could  be 
affixed  to  the  victim  of  such  a-  malady  by  reason  of  the 
fact  of  infection.  In  the  populous  and  crowded  centres 
of  modern  civilization  the  innocent  subjects  of  these  dis- 
orders are  numbered  by  hundreds  and  even  thousands. 
They  are  in  a  special  sense  entitled  to  the  encouraging 
assistance  and  the  sympathetic  service  of  the  trained 
physician. 

The  great  majority  of  the  other  victims  are  patients 
infected  at  a  time  of  life  when  passion  is  most  imperi- 
ous, self-restraint  less  strenuously  imposed,  and  the  dis- 
cipline which  unfolds  the  deeper  meanings  of  life  is  less 
understood  and  appreciated.  The  result  is  twofold  :  on 
the  one  hand  are  patients  for  the  most  part,  fortunately, 
of  an  age  and  possessed  of  a  vigor  best  capable  of  endur- 
ing without  serious  shock  the  perils  of  an  intoxication 
of  the  system,  and  in  a  social  state  least  likely  to  burden 
others,  such  as  a  wife  or  a  child,  with  the  consequences 
of  disease ;  on  the  other  hand  are  the  subjects  of  these 
infections,  who,  without  fixed  habits,  are  obliged  to  con- 
form to  the  rules  of  best  living  when  actually  suffering 

2  17 


1 8        SYPHILIS  AXD    THE    VENEREAL   DISEASES. 

from  their  ailments,  and  who  learn  lessons  which  at 
their  time  of  life  are  often  indelible.  The  most  radical 
of  moral  reforms  with  the  best  of  ultimate  results  is  con- 
stantly wrought  by  the  several  accidents  described  in  the 
following  pages. 

In  the  early  part  of  this  century  the  prejudices  of  the 
people  of  most  English-speaking  countries  and  the 
odium  connected  with  the  acquisition  and  inheritance 
of  venereal  disease  extended  even  to  the  professional 
men  interested  in  their  treatment.  As  a  consequence, 
this  department  of  medicine  was  largely  relegated  to 
the  charlatan,  who,  under  the  control  of  ignorance  and 
avarice,  contributed  to  the  exaggeration  and  confusion 
which  still  cloud  the  minds  of  many  when  they  consider 
the  subject. 

To-day  the  change  in  these  particulars  is  noteworthy. 
Science  has  solved  some  of  the  profoundest  problems 
and  achieved  some  of  its  most  brilliant  bacteriological 
and  pathological  victories  in  the  territory  once  aban- 
doned as  a  plague-spot.  Some  of  the  most  cultivated, 
learned,  and  distinguished  of  the  physicians  of  the  last 
quarter  of  the  nineteenth  century  have  been  content  to 
labor  and  to  glean  in  the  field  that  was  thus  once 
neglected  and  abhorred. 

It  has  been  well  for  the  race  that  these  men  could 
thus  with  untiring  industry  and  interest  investigate  the 
diseases  commonly  described  as  "  loathsome."  But 
many  of  them  have  paid  a  price  for  their  courage.  It  is 
impossible  to  give  accurate  statistics  of  the  number  of 
physicians  innocently  infected  with  the  venereal  diseases, 
and  particularly  with  syphilis,  when  engaged  in  the 
practice  of  their  profession  as  accoucheurs,  surgeons, 
gynecologists,  and  those  giving  special  attention  to  the 
affections  of  the  genito-urinary  organs  of  both  sexes. 
Hundreds  of  them  have  been  under  our  observation  and 
care ;  thousands  have  thus  suffered  in  every  country. 
Only  with  the  incessant  precautions  suggested  by  the 
later  knowledge  on  the  subject  of  the  pathogenic  micro- 


INTRODUCTION.  1 9 

organisms  can  a  physician  hope  to  be  successful  in  the 
management  of  these  disorders  and  himself  escape  their 
defilement.  Nor  in  his  attempts  to  compass  this  end 
can  he  with  safety  rely  only  upon  the  products  of 
pharmacy  and  the  skill  of  the  chemist.  He  must  be,  in 
his  person,  his  instruments,  and  his  entourage,  an 
embodiment  of  scrupulous  cleanliness. 

The  disorders  usually  classed  under  the  general  title 
of  "  venereal "  are  syphilis,  the  several  forms  of  infec- 
tious urethritis,  and  the  soft  ("  simple  "  or  "  non-syphi- 
litic") chancre.  In  a  stricter  sense  of  the  term,  and  in 
the  light  of  modern  investigation,  there  are  other  dis- 
orders described  in  these  pages  capable  of  transmis- 
sion in  the  sexual  act.  The  mere  important,  however, 
of  the  group  are  without  question  those  here  named. 
It  is  probable,  though  exact  statistics  are  wanting, 
that  infectious  urethritis  is  the  most  frequent,  soft 
chancre  (certainly  in  particular  classes  of  society)  next, 
and  syphilis,  in  all  classes,  last.  Further  comparison 
teaches  that  while  gonorrhoea  is  most  often  a  strictly 
venereal  disorder,  syphilis  is  with  greater  frequency  an 
affection  of  the  innocent ;  while,  as  respects  a  fatal  issue, 
gonorrhoea,  in  its  ultimate  results  upon  the  deep  urethra, 
the  bladder,  and  the  kidneys,  probably  destroys  more 
lives  annually  than  does  syphilis.  Gonorrhoea  more 
often  than  syphilis  spares  the  subjects  of  tender  age, 
and  is  further  capable  of  indefinite  recurrence  in  one 
subject ;  while  for  the  immense  majority  of  cases 
syphilis  is  a  disease  making  but  a  single  attack  in  the 
lifetime  of  the  individual.  The  proposition  once  held 
cannot  longer  be  sustained,  that  gonorrhoea  and  soft 
chancre  are  purely  local  diseases  as  contrasted  with 
syphilis,  which  is  admitted  to  have  systemic  effects. 
The  generalized  results  of  gonorrhoea  are  in  many 
instances  too  striking  to  admit  even  of  question ;  and  in 
special  cases  the  perpetuation  of  the  soft  chancre  for 
years,  with  the  damage  resulting  to  rectum,  vulva, 
abdominal    wall,    and    thigh,    with    the    production    of 


20        SYPHILIS  AND    THE    VENEREAL   DISEASES. 

marked  cachexia,  often  renders  that  affection  one  even 
of  greater  severity  than  the  milder  cases  of  syphilis. 

The  questions  relating  to  the  history  and  antiquity  of 
the  venereal  diseases  have  created  a  voluminous  litera- 
ture, with  results  not  wholly  satisfactory.  The  sacred 
literature  of  the  Hebrews  seems  to  bear  record  to  the 
fact  that  blennorrhagic  affections  existed  among  the 
people  of  a  remote  antiquity,  and  that  the  gonorrhceal 
discharge  was  with  them  confounded  with  a  seminal 
flow.  Among  the  writings  of  Greek,  Roman,  African, 
and  Spanish  authors,  both  medical  and  literary,  evi- 
dences are  not  wanting  as  to  the  existence  of  such  a 
disease  and  its  occasional  confusion  with  other  disorders 
of  a  venereal  origin.  Even  as  early  as  the  beginning  of 
the  present  century,  English  physicians  confounded 
gonorrhoea,  syphilis,  and  non-syphilitic  chancre,  and  it 
was  reserved  for  a  comparatively  recent  date  to  distin- 
guish definitely  and  finally  between  them. 

For  the  remote  antiquity  of  syphilis  there  are  not 
wanting  authors  who  find  in  the  sacred  writings  of  the 
Hebrews,  in  the  sarcastic,  poetical,  and  historical  litera- 
tures of  Greece  and  Rome,  in  the  ancient  documents  of 
Egypt,  China,  and  Africa,  and  in  the  volumes  written 
during  the  Middle  Ages,  records  among  the  people  of 
those  periods  of  the  existence  of  chancres  and  of  the 
systemic  results  of  certain  genital  lesions.  The  evi- 
dence of  bones  exhumed  and  supposed  to  belong  to 
a  prehistoric  era  is  also  adduced  in  support  of  the 
assumed  antiquity  of  syphilis.  On  the  other  hand,  there 
are  many  who  believe  that  syphilis  existed  among  the 
American  aborigines  before  the  advent  in  1492  of 
Columbus  and  his  companions  to  the  American  coast, 
and  that  the  Spaniards,  becoming  infected  by  contact 
with  the  natives,  brought  the  disease  to  Europe,  where 
it  appeared  for  the  first  time  after  their  return.  In  the 
subsequent  campaign  of  Charles  VIII.  of  France  against 
the  kingdom  of  Naples  the  disease  appeared  and  spread 


INTR  OD  UCTION.  2 1 

among  the  nations  of  Europe  to  an  extent  and  with  a 
severity  before  then  unknown. 

In  reviewing  the  entire  subject  many  of  the  argu- 
ments in  favor  of  the  historical  antiquity  of  these 
diseases  are,  it  must  be  admitted,  weakened  by  the 
indefiniteness  of  the  descriptions  given.  The  bones 
alleged  to  be  both  prehistoric  and  syphilitic  are  either 
lacking  in  the  display  of  unmistakable  lesions  of  that 
disease  or  cannot  conclusively  be  demonstrated  to  be 
both  of  prehistoric  sepulture  and  since  then  wholly 
undisturbed  by  the  hand  of  man.  The  arguments  in 
favor  of  a  prehistoric  syphilis  in  America  and  of  its 
subsequent  deportation  to  Europe  are  weighty,  but  not 
without  flaw. 

The  conclusions  are  simple :  the  evidence  of  a  remote 
antiquity  for  the  venereal  diseases  in  general  is  very 
strong.  In  the  absence  of  the  definite  distinctions 
between  them  now  established,  and  of  a  recognition  of 
the  pathological  connection  between  the  local  mani- 
festations of  such  diseases  and  their  systemic  effects, 
great  confusion  has  existed  in  the  past.  Lastly,  the 
venereal  diseases  have  all,  without  question,  been  con- 
fused inextricably  in  the  past,  not  merely  with  each 
other,  but  with  a  large  number  of  dermatological  affec- 
tions, such  as  lepra,  psoriasis,  scabies,  eczema,  simple 
and  venereal  warts,  and  leucorrhceal  and  catarrhal 
discharges. 

In  the  examination  of  patients  affected  with  one  or 
several  of  the  disorders  here  considered,  a  systematic 
method  is  of  as  much  value  as  in  other  departments 
of  medicine.  Besides  ascertaining  the  name,  age,  resi- 
dence, married  state,  occupation,  and  previous  history 
of  the  patient,  as  well  as  the  habits  respecting  the  use 
of  both  alcohol  and  tobacco,  it  is  desirable  to  know,  for 
reasons  that  appear  later,  in  the  case  of  both  man  and 
woman,  the  record  as  respects  living  and  dead  children, 
miscarriages  and  abortions  on  the  part  of  a  wife,  and 
the.  relative   order    of  these,   as  well  as   the   period   in 


22         SYPHILI'S  AND    THE   VENEREAL   DISEASES. 

pregnancy  when  a  series  of  abortions  or  miscarriages 
occurred.  In  securing  the  history  of  the  family  and  of 
any  antecedent  disease  it  is  necessary  to  record  all  facts 
respecting  any  prior  disease  of  the  skin,  persistent  head- 
ache, especially  with  nocturnal  exacerbation,  any  attacks 
supposed  to  be  rheumatic,  and  any  persistent  or  ulcera- 
tive affection  of  the  throat,  eyes,  scalp,  or  nails. 

In  the  case  of  venereal  disease  it  is  important  to 
know  whether  the  patient  can  sleep  at  night  without 
rising  from  the  bed  to  empty  the  bladder;  whether 
there  is  pain  on  micturition,  and,  in  the  latter  event, 
whether  the  pain  occurs  before,  during,  or  after  the 
passage  of  the  stream. 

In  the  physical  examination  of  patients  the  several 
bodily  organs  should  be  investigated  with  care,  the 
surface  of  the  body,  when  found  practicable,  being 
searched  for  traces  of  any  existing  or  past  exanthem, 
and  particularly  for  scars,  each  of  which  may  throw 
light  on  the  conditions  existing.  The  superficial  glands 
of  the  body  accessible  to  the  fingers  should  be  searched 
with  a  view  to  determining  any  enlargement  or  indura- 
tion. The  mouth,  nostrils,  eyes,  and  ears  require 
minute  observation  of  lesions  present;  and  even  in  the 
absence  of  the  latter  the  nails  may  exhibit  markings 
indicative  of  the  character,  and  at  times  of  even  the 
date,  of  prior  nutritional  changes. 

In  the  case  of  male  patients  the  entire  surface  of  the 
body  may  often  be  exposed  for  examination,  and  the 
genital  region  then  requires  detailed  inspection.  By  the 
fingers  and  the  eye  the  physician  can  usually  determine 
the  existence  of  pediculi  or  nits  in  the  pubic  region,  an 
eczema  or  a  psoriasis  of  the  cutaneous  surface  of  the 
penis  or  the  scrotum,  mollusca  of  the  latter  region,  or 
the  evidence  of  scabies.  By  manipulation  it  will  be 
discovered  whether  there  is  an  inguinal  hernia,  a  non- 
descended  testis,  a  left-  or  more  rarely  a  right-sided  vari- 
cocele, a  gumma  of  the  body  of  the  testicle,  or  traces 
of  an  ancient  epididymitis  involving  the  globus  minor 


INTRODUCTION.  27, 

or  major  as  a  sequel  of  a  preceding  blennorrhagia.  By 
the  fingers  alone  it  will  often  be  practicable  to  recognize 
a  urethral  stricture,  a  periurethral  phlegmon,  an  en- 
larged prostate,  a  syphilitic  or  a  chancroidal  bubo,  a 
severe  phimosis,  a  subpreputial  sclerosis  or  other  lesion, 
or  a  urethral  chancre.  In  point  of  fact,  a  urethral 
sclerosis  that  cannot  be  recognized  by  the  digit  of  the 
trained  physician  is  among  the  greatest  of  rarities. 
Indeed,  one  might  here  enumerate  the  entire  list  of 
diseases  of  the  ano-genital  region,  evidences  of  which 
the  examining  surgeon  should  not  permit  to  escape  his 
observant  eye  and  trained  touch. 

In  all  classes  of  women  the  examination  should  be 
made  with  the  special  consideration  to  which  the  sex  is 
entitled.  A  follicular  or  furuncular  affection  of  the 
labia,  a  catarrhal  discharge  from  the  vulva,  a  sclerosis 
of  the  meatus  or  of  the  fourchette,  or  a  stellate  chancroid 
of  the  anal  region,  may  often  be  determined  by  inspec- 
tion alone.  The  physician  must  know  to  distinguish 
between  a  languette  accompanying  a  syphilitic  stricture 
of  the  rectum  and  a  hemorrhoidal  tumor.  He  must  be 
capable  of  recognizing  the  marked  differences  between 
a  pruritus  of  the  vulva,  which  is  simply  tormented  by 
scratching,  and  an  eczema  of  the  same  part.  By  carefully 
inspecting  the  dry  and  "  sticky  "  mouth  of  a  woman  it  can 
be  determined  with  reasonable  probability,  before  subject- 
ing the  urine  to  chemical  analysis,  that  an  "  eczema  "  of 
the  vulva  is  due  simply  to  a  glycosuria.  The  fingers 
should  differentiate  an  inflammation  of  the  vulvo-vaginal 
gland  due  to  gonorrhoea  from  a  syphiloma  of  the 
labium.  Scabies  of  the  genital  region  in  a  woman  will 
usually  be  an  echo  of  characteristic  burrows  about  the 
axillae  or  the  breasts.  By  the  touch  one  should  be  able 
to  discover  a  hydrocele  of  the  canal  of  Nuck,  a  varico- 
cele, a  carcinoma,  an  elephantiasis,  a  contracture  of  the 
vagina,  a  laceration,  an  atresia  of  the  hymen,  or  a 
vaginismus. 

Nor  should  it  be  concluded  in  either  sex  that  a  deter- 


24        SYPHILIS  AND    THE  VENEREAL   DISEASES. 

mination  of  the  virgin  state  precludes  the  possibility  of 
venereal  disease.  The  physician  should  ever  be  on  the 
alert  to  recognize  a  chancre  of  the  tonsil,  an  infecting 
sclerosis  of  the  lip  in  the  child  who  has  kissed  a 
syphilitic  nursling,  a  gonorrhoea  affecting  the  vulva  or 
the  eyes  of  an  infant,  a  paralysis  in  the  middle  period 
of  life  due*  rather  to  a  pachymeningitis  than  to  an  apo- 
plectic effusion. 

Lastly,  the  physician  entrusted  with  an  intimate 
knowledge  of  the  sources  of  diseases  that  are  viewed 
with  shame,  loathing,  and  remorse,  often  imperilling  the 
life  of  the  individual,  the  safety  of  the  uninfected,  and 
the  happiness  of  a  home,  has  a  part  to  perform  which 
demands  a  high  order  of  intelligence  and  sympathy. 
His  it  is  to  protect  the  innocent,  to  guard  sacredly  the 
secrets  confided  to  his  keeping,  to  conserve  the  family 
relation,  and  at  the  same  time  to  bring  the  sufferer  to  a 
successful  termination  of  the  disease.  It  is  difficult  to 
decide  that  any  one  of  these  functions  has  a  higher 
importance  than  another.  It  is  only  as  the  physician 
discharges  his  full  duty  in  all  points  that  he  ultimately 
wins  that  trust  and  confidence  which  are  the  foundation 
of  the  largest  professional  success. 


SYPHILIS. 


Synonyms. — Lues  venerea ;  Morbus  galliclis  ;  Pox  ; 
"Bad  disorder;"  Fr.  Verole;  Ital.  Sifilide ;  Ger.  Lust- 
seuche ;  Krankheiten  der  Franzosen ;  Span.  Sifilis  ; 
Sweet.  Radezyge. 

Syphilis  is  a  general  infectious  disorder  transmitted 
from  one  individual  to  another  by  both  contact  and 
inheritance,  chronic  in  course,  and  displaying  in  a  more 
or  less  determinate  sequence  symptoms  involving  one 
or  several  of  the  organs  of  the  body.  It  is  classed  with 
the  infectious  granulomata,  and  it  is  due  to  the  toxic 
effect  of  the  invasion  of  the  bodily  tissues  by  a  morbific 
germ.  Though  the  identity  and  relations  of  the  latter 
have  not  completely  been  established  (as  has  been  done 
in  the  case  of  the  bacilli  of  tuberculosis  and  lepra),  no 
doubt  can  be  entertained  as  to  its  existence  and  potency. 

ACQUIRED   SYPHILIS. 

Syphilis  is  said  to  be  acquired  when  transmitted  in 
another  way  than  by  inheritance.  The  term  "  contact- 
syphilis  "  has  also  been  employed  to  distinguish  the 
former  from  the  latter. 

Etiology. — The  micro-organisms  which  are  effective 
in  the  production  of  this  disease  have  not  yet  been 
incontestably  demonstrated.  Donne,  Hallier,  Lostorfer, 
Klebs,  Doutrelepont,  Lustgarten,  Fordyce,  and  many 
others  have  repeatedly,  by  difficult  and  delicate  methods 
of  staining,  recognized  bacilli  in  syphilitic  tissue.  The 
failure  to  distinguish  the  exact  micro-organism  whose 
toxine  may  be  efficient  as  a  cause  of  the  disease  is  due 
partly  to  the  fewness  of  the  bacilli  present  in  any  one 
section,  to  the  circumstance  that  the  bacilli  found  in  the 
smegma  prseputii  are  either  identical  with  or  very  sim- 

25 


26         SYPHILIS  AND    THE   VENEREAL   DISEASES. 

ilar  to  the  supposed  syphilitic  germ,  and  to  a  fact 
pointed  out  by  Fordyce,  that  the  general  absence  of 
giant-cells  in  syphilitic  tissue  forbids  their  use  as  a 
guide  to  the  location  of  the  bacilli. 

But  if  the  germ  of  the  disorder  has  not  yet  been 
distinguished  satisfactorily,  no  doubt  exists  as  to  the 
fact  that  a  germ-carrying  secretion  or  virus,  which  may 
be  collected  on  the  point  of  a  lancet,  is  capable  of  trans- 
mitting the  disease.  This  virus  must  be  furnished  by  a 
person  infected  with  syphilis. 

The  purveyors  of  this  virus  are  usually  in  an  early  or 
active  stage  of  the  disease.  They  may  furnish  a  patho- 
logical secretion,  such  as  that  supplied  by  a  mucous 
patch,  a  chancre,  a  syphilitic  pustule,  or  an  ulcer.  Such 
a  secretion  may  be  commingled  with  a  physiological 
fluid  (tears,  saliva,  milk),  and  be  thus  effective,  however 
innocent  to  the  view,  though  the  physiological  secre- 
tions of  a  syphilitic  subject  not  thus  mingled  with  a 
virus  are  rarely,  if  ever,  noxious.  The  blood  of  such 
subjects  is,  however,  capable  of  transmitting  the  disease. 
Pathological  secretions  of  other  character  (gonorrhceal, 
leucorrhoeal,  vaccinal)  may  readily  be  commingled  with 
the  virus  of  syphilis,  and  thus  be  effective  in  its  trans- 
mission. 

The  evidence  as  to  the  date  when  the  syphilitic 
subject  can  no  longer  furnish  an  infectious  virus  is  con- 
fusing. Up  to  a  recent  time  it  was  believed  that  the  late 
lesions  of  syphilis  (so-called  "  tertiary  ")  were  incapable 
of  furnishing  such  a  virus.  Instances  are,  however,  on 
record  disproving  this ;  and,  though  the  power  to 
furnish  a  virus  is  gradually  lost  in  every  surviving 
subject  of  syphilis,  it  is  safest  to  hold  that  any  awaken- 
ing of  the  morbid  process  at  a  late  date  may,  however 
rarely,  render  such  persons  dangerous  to  the  uninfected. 

The  modes  of  infection  are  both  immediate  and 
mediate.  The  direct  contacts  of  the  sexual  act  (includ- 
ing the  perverted  and  unnatural  imitations  of  the  latter) 
and  the  opportunities  of  transmission  afforded  in  kiss- 


ACQUIRED  SYPHILIS.  2J 

ing,  biting,  sucking,  etc.  often  provide  for  the  beginnings 
of  syphilis.  In  the  same  category  may  be  named  all 
the  accidental  contacts  which  occur  in  the  service  of  the 
physician,  the  nurse,  and  the  midwife,  and  those  where 
prisoners  are  manacled  together. 

The  articles  which  have  been  mediately  effective  as 
virus-carriers  are  so  many  and  so  various  as  to  forbid 
enumeration.  The  list  includes  a  great  number  of 
household  utensils  (forks,  cups,  spoons),  articles  of 
domestic  use  (tooth-brushes,  syringes,  combs),  articles 
employed  in  the  professions  (dentists'  forceps,  surgical 
instruments  and  appliances,  razors,  vaccinating  needles, 
lancets),  and,  in  brief,  almost  every  substance  brought 
into  contact  with  the  human  body,  from  nursing-bottle 
to  water-closet  seat,  and  from  the  finger  moistened  in 
the  mouth  of  the  nurse  and  given  to  the  nursling  to  the 
tools  of  the  chiropodist. 

Given  an  infective  germ  in  its  vehicle  (the  virus), 
furnished  by  an  infected  subject  of  syphilis  (in  a  stage 
of  that  disease  capable  of  transmissibility  by  contact),  it 
remains  to  inquire  whether  the  person  inoculated  with 
such  a  virus,  mediately  or  immediately  conveyed,  will 
suffer  from  the  disease.  A  categorical  answer  to  this 
question  cannot  be  given.  There  is  reason  to  believe 
that  all  individuals  are  not  equally  susceptible  to  the 
action  of  the  virus.  These  reasons  are  based  on  the 
accepted  fact  of  repeated  exposures  of  certain  persons 
without  evident  results ;  of  repeated  exposures  with 
results  that  are  slight,  or,  if  threatening  at  first,  abortive 
as  to  any  ultimate  consequences ;  and  of  well-known 
analogies  existing  between  this  disease  and  others 
in  which  the  proofs  of  susceptibility  and  non-suscepti- 
bility of  individuals  are  irrefragable. 

All  such  instances  are,  however,  exceptions  to  a  rule 
that  is  enforced  by  constant  experience.  The  husband 
recently  infected  as  a  result  of  infidelity  to  his  wife 
communicates  his  disease  to  the  latter  with  almost 
unfailing    regularity;    the    lover    with   a    mucous   patch 


28         SYPHILIS  AND    THE  VENEREAL   DISEASES. 

upon  his  lip  gives  his  disorder  with  an  appalling  cer- 
tainty to  the  woman  whom  he  kisses  upon  the  mouth. 
For  practical  purposes  it  is  best  to  assume  that  all  men, 
women,  and  children  are  susceptible  who  have  not  been 
protected  either  by  a  previous  attack  of  the  disease  or 
(a  point  to  which  attention  is  called  later)  by  the 
experience  of  the  mother  who  brings  into  the  world  a 
syphilitic  child  diseased  by  inheritance  from  the  father, 
while  she  seems  to  escape. 

Chancre. 

Synonyms.  —  Syphilitic  chancre ;  Initial  lesion  or 
sclerosis  of  syphilis  ;  Hard  chancre  ;  Infecting  chancre  ; 
Ger.  Hartes  Geschwur;  Schanker;  Fr.  Chancre  syph- 
ilitique. 

The.  first  evidence  of  a  successful  transmission  of 
syphilis  from  an  infected  to  a  sound  person  is  termed  a 
"  chancre,"  or,  as  this  last  term  has  often  been  errone- 
ously applied  to  non-syphilitic  local  venereal  disorders, 
better  the  "  initial  lesion  of  syphilis." 

The  First  Incubation. — After  the  successful  intro- 
duction of  the  syphilitic  virus  into  a  sound  body  an 
interval  occurs  before  the  evolution  of  the  initial  lesion 
is  appreciable  to  the  eye.  This  interval  is  called  the 
"  period  of  the  first  incubation,"  a  phrase  suggestive  of 
the  ignorance  of  the  earliest  observers.  It  is  almost 
certain  that  from  the  instant  of  a  successful  inoculation 
the  subject  is,  however  imperceptibly  to  human  tests, 
syphilitic,  and  that  there  is,  without  pause  or  arrest,  a 
multiplication  of  the  effective  germs  of  the  disease  to  the 
point  where  the  lesions  produced  by  these  germs  become 
apparent  to  coarse  methods  of  observation.  This  interval 
is  by  different  observers  made  to  extend  over  a  period  of 
time  with  singularly  varying  limits.  The  average  is 
between  fifteen  and  twenty-six  days,  but  the  period  has 
been  claimed  to  be  as  brief  as  from  one  to  two  days 
and  as  extended  as  three  months.  The  numerous 
chances  of  error  in  all  these  estimates  need  not  be  pointed 


ACQUIRED  SYPHILIS.  29 

out.  Between  ten  and  thirty  days  after  infection  the  vast 
majority  of  all  infecting  chancres  appear.  The  reverse 
is  also  true  :  on  the  first  appearance  of  a  chancre  it  may 
safely  be  estimated  that  infection  occurred  previously 
between  ten  and  thirty  days. 

The  chancre  or  syphilitic  initial  lesion  appears  at  the 
site  of  inoculation.  Its  recognition,  when  first  exhibited 
as  the  earliest  indication  of  a  serious  disease,  is  a  matter 
of  the  profoundest  importance,  seeing  that  the  welfare 
of  the  individual,  and  often  of  others  with  whom  he  sus- 
tains intimate  relations,  may  be  conditioned  upon  its  cor- 
rect diagnosis. 

The  chief  error  committed  by  the  practitioner  and 
student  anxious  to  master  this  problem  lies  in  an  effort 
to  identify  some  particular  chancre  as  a  type  of  all 
others,  and  to  base  a  diagnosis  upon  a  comparison  of 
others  with  this  as  a  type.  This  is  the  familiar  process 
by  which  men  recognize  in  nature  a  flower  or  a  bird, 
and  in  medicine  a  disease  of  so  fixed  a  type  as  a  corn  or 
a  carbuncle. 

The  sole  constant  characteristics  of  every  chancre  are 
— (a)  an  incubative  period  preceding  its  appearance  ;  (b) 
a  sclerosis,  induration,  or  dense  thickening  of  the  base 
of  the  lesion,  widely  varying  in  grade  and  duration  with 
different  chancres ;  (c)  a  simultaneous  enlargement  and 
induration  of  the  gland  or  glands  in  nearest  anatomical 
relation  with  the  chancre,  constituting  the  "  syphilitic 
bubo,"  or  primary  adenopathy.  The  first  of  these  con- 
stant characteristics  is  an  historical  symptom,  a  knowl- 
edge of  which  may  be  withheld  from  the  practitioner  at 
the  date  of  his  examination.  The  last,  though  wellnigh 
constant  of  occurrence,  may  not  have  been  declared  fully 
at  the  date  of  the  examination,  or  the  glandular  enlarge- 
ment may  be  so  slight  or  so  deeply  situated  as  to  escape 
detection.  It  follows  that  in  some  cases  it  is  possible 
that  at  a  given  moment  the  sclerosis  may  be  the  sole 
chancre-symptom  present  whereby  the  nature  of  the 
disorder  may  be  declared.     Yet  there   are   several  non- 


30        SYPHILIS  AND    THE  VENEREAL   DISEASES. 

constant  symptoms  which  can  usually  be  recognized 
without  difficulty,  and  which  leave  the  observer  in  little 
doubt  as  to  the  diagnosis.  These  symptoms  are  for  the 
most  part  explained  later. 

A  chancre  is  a  modification  of  the  sound  or  patho- 
logically altered  skin  or  mucous  membrane,  occurring 
after  syphilitic  infection,  and  displayed  after  an  incu- 
bative period,  characterized  by  a  circumscribed  sclerosis 
of  tissue,  and  accompanied  by  an  enlargement  and  indu- 
ration of  neighboring  glands.  Every  chancre  means  a 
syphilis,  mild  or  severe,  that  will  follow.  Every  case  of 
acquired  syphilis  points  to  a  precedent  chancre,  recog- 
nized or  unrecognized.  Every  chancre,  further,  is  a 
symptom  not  merely  of  a  syphilis  that  will  follow,  but 
of  a  syphilis  actually  present.  The  proof  is  found  in 
the  fact  that  infection  of  a  sound  individual  from  such  a 
chancre  is  followed  by  the  development  not  merely  of  a 
new  chancre,  but  also  of  a  new  syphilis. 

It  is  important  to  note  at  the  outset,  considering  the 
definition  given  above,  that  a  chancre  may  be  either  an 
isolated  first  lesion  of  syphilis  or  a  modification  of  some 
symptom  of  another  disease.  Briefly,  the  study  of 
chancres  is  the  study  less  of  lesions  than  of  a  series  of 
singular  modifications  of  lesions  recognized  in  many 
other  diseases,  which,  under  the  influence  of  syphilis, 
take  on  new  aspects  and  undergo  singular  metamor- 
phoses. Thus,  the  chancre  may  develop  upon  the 
sound  skin  of  the  arm  as  a  consequence  of  intentional 
experimental  inoculation,  or  upon  the  sound  mucous 
membrane  of  the  vulva  as  the  result  of  infection  in  the 
sexual  act.  It  may  also  originate  as  an  untoward  modi- 
fication of  a  "cold  sore"  (herpes  labialis)  of  the  mucous 
membrane  of  the  lip  infected  in  the  act  of  kissing,  or  be 
a  significant  change  in  the  evolution  of  a  vaccine  vesicle, 
a  blister  on  the  finger,  or  an  excoriated  nipple. 

Chancres  may  thus  be  represented  at  one  time  or 
another  by  every  recognized  lesion  of  the  cutaneous 
surface,  including  the  macule,  papule,  vesicle,  pustule, 


Plate  i. 


Plate  2. 


Chancre  and  papillary  growths  of  the  tongue  (Hutchinson). 


ACQUIRED  SYPHILIS.  3 1 

bleb,  tubercle,  tumor,  and  ulcer.  Only  the  most  com- 
mon types  can  here  be  enumerated  conveniently. 

Erosion  (Superficial  erosion). — This  is  the  least  con- 
spicuous, the  oftenest  ignored  or  misunderstood,  and  yet 
the  commonest  of  chancre  symptoms.  It  is  recognized  as 
a  roundish,  oval,  or  quite  irregular  macule  or  spot  with  a 
smooth  or  polished  face,  resting,  soon  after  its  evolution, 
upon  a  delicate  bed  of  induration,  giving  to  the  touch  the 
sensation  of  a  thin  sheet  of  parchment  or  of  mica  let  into 
the  underlying  tissue.  It  is  usually  distinctly  circum- 
scribed, and  exhibits  a  shallow  or  scarcely  depressed  ero- 
sion, centrally  fixed  or  involving  its  entire  face.  In  size  it 
varies  from  a  large  pin-head  to  a  bean,  and  may  be  many 
times  larger.  Its  color  is  dull-reddish,  grayish,  or  even 
whitish ;  it  often  resembles  in  hue  a  section  of  raw  ham. 
It  may  be  dry  and  glazed,  or  slightly  moist  and  secret- 
ing a  thin  serum  which  glues  to  its  surface  any  dressings 
that  may  have  been  applied  to  it.  At  times  it  has  a 
grayish-white  film  over  its  face,  and  may  even  have  a 
diphtheroid  aspect.  It  may  be  uniformly  level  with  the 
neighboring  skin,  or  its  edges  may  be  raised  and  its  cen- 
tre slightly  depressed.  It  very  rarely  suppurates  freely 
or  degenerates  into  a  well-marked  ulcer.  These  com- 
plications usually  result  from  external  irritation  (caustics, 
mixed  infection,  urine  flowing  over  the  site,  as  in  urethral 
chancre).  The  accidents  of  phagedena  and  sloughing 
are  still  rarer.  When  these  chancres  survive  until  gen- 
eral syphilis  is  declared,  they  are  gradually  transformed 
into  symptoms  of  general  syphilis,  readily  enlarging 
to  elevated,  granulating,  rarely  hemorrhagic  masses 
smeared  with  a  highly  contagious  puriform  mucus  and 
merging  thus  into  the  mucous  patch  and  condyloma. 

These  erosions  may  be  lifted  away  from  their  original 
sites  by  extensive  underlying  scleroses,  and  be  thus 
greatly  modified  in  appearance.  They  are  then  changed 
from  flat  macules  to  large-nut-sized  and  even  larger 
irregularly  outlined  masses,  ridges,  and  deformations 
of  the  lip,  the  vulva,  or  the  preputial  rim — favorite  sites 


32        SYPHILIS  AND    THE  VENEREAL  DISEASES. 

for  their  development.  These  odd-looking  swellings, 
unlike  each  other  and  conspicuous  chiefly  for  their 
irregular  bulging,  often  as  firm  as  ivory  to  the  touch, 
are  capped  at  one  point  or  another  by  the  smooth,  shal- 
low, dry  and  glazed  or  slightly  secreting  erosion 
described  above.  All  are  essentially  giant-papules, 
undergoing  a  special  evolution  because  of  the  pressure- 
and  friction-effects  of  their  particular  environment. 

Papule  (Dry  scaling  papule;  Non-ulcerating,  indurated 
papule). — This  is  the  common  result  of  inoculation  of 
the  skin  as  distinguished  from  that  of  the  mucous  sur- 
face. The  chancre  is  here  evolved  as  a  pea-  to  a  bean- 
sized  papule  or  papulo-tubercle,  indurated  at  the  base, 
dry,  scaling,  and  colored  in  various  shades,  according  to 
its  situation.  It  is  occasionally  seen  upon  the  skin  of 
the  penis  as  the  result  of  accidental  infection  of  that 
part,  and  upon  other  cutaneous  surfaces,  as  the  thigh 
and  the  arm,  as  the  result  of  accidental  or  experimental 
inoculation. 

Ulcer. — Ulceration  of  the  chancre  is  probably  in  every 
case  the  result  of  local  irritation.  This  irritation  maybe 
accidental,  as  in  the  case  where  improper  dressings  or 
applications  are  made  to  the  lesions,  or  intentional,  as 
where  savin  cerate  has  been  applied  or  horse-hairs  have 
been  passed  through  the  base  for  the  purpose  of  exciting 
suppuration  with  a  view  to  supplying  a  virus  for  purposes 
of  experimentation.  Two  types  of  ulceration  may  be 
recognized  in  chancres,  the  shallow  and  the  deep.  Both 
occur  in  beds  of  induration.  Their  causes  have  been 
discussed  above ;  maceration  (by  mucus,  by  leucor- 
rhceal  and  blennorrhagic  discharges),  friction,  improper 
treatment  by  local  applications,  filth,  and  neglect  may 
all  be  cited  as  of  consequence. 

Shallow  and  superficial  ulcers,  scantily  secreting  serum, 
are  usually  imbedded  like  erosions  in  thin  sheets  of 
induration,  but  they  may  cap  considerable  elevations  of 
tissue.  Their  edges  are  sloping,  almost  never  clean-cut, 
punched  out,  or  undermined  ;  their  floors  rarely  slough  ; 


ACQUIRED  SYPHILIS.  33 

their  outline  is  irregular.  At  times  they  resemble  shal- 
low fissures,  especially  on  the  side  of  the  fraenum ;  at 
others  they  form  at  the  bottom  of  a  crevice  between  two 
walls  of  induration,  as  when  the  sclerosis  involves  the 
mucous  membrane  of  both  the  corona  glandis  and  the 
adjacent  prepuce. 

Deep  ulceration  of  chancres  invariably  results  from 
the  action  in  excess  of  the  causes  suggested  above,  or 
from  similar  agencies.  The  "  Hunterian  chancre,"  so 
named  because  Mr.  Hunter  believed  that  it  was  the  sole 
precursor  of  general  syphilis,  is  a  deep  excavation  in  a 
large  mass  of  induration.  This  crateriform  ulcer  is 
roundish,  oval,  or  very  irregularly  shaped,  often  with  a 
floor  set  in  an  angle,  presenting  thus  the  aspect  of  a 
deep  fissure  in  a  neoplasm.  Its  secretion  is  commonly 
scanty,  though  when  profuse  it  may  be  hemorrhagic  ; 
its  edges  are  sloping;  its  rim  is  densely  indurated,  cap- 
ping a  tumor-like  mass  varying  in  size  from  a  hazelnut 
to  that  of  a  pullet's  egg. 

Other  rare  types  of  chancres  are  described  by  authors. 
Among  them  may  be  named  the  silvery  spot,  described 
by  Taylor,  where  a  pin-head-sized  macule  resembling  a 
surface  of  mucous  membrane  touched  by  nitrate  of  silver 
develops  on  the  glans  or  lips  of  the  meatus  externus  in 
male  patients,  and  afterward  increases  in  size ;  the  "  um- 
bilicated  papule,"  or  follicular  chancre,  in  which  minute 
and  enlarging  cup-shaped  lesions  of  a  light  reddish  hue  de- 
velop ;  the  "  multiple  herpetiform  chancres"  of  Dubuc, 
which  are  really  multiple  and  at  first  minute  excoriations 
having  a  hemorrhagic  tendency,  with  a  smooth,  shining 
surface,  and  which,  if  the  chronicity  of  their  course  be  not 
considered,  are  liable  to  be  mistaken  for  the  lesions  of  sim- 
ple herpes  progenitalis  (q.  v.);  the  "incrusted  chancre" 
— that,  viz.,  in  which  a  crust  occurs  over  an  excoration, 
papule,  or  erosion  which  has  been  for  any  reason  irritated 
to  the  point  of  furnishing  a  secretion,  which  then  desic- 
cates into  a  greenish,  dirty-brown,  or,  when  blood  has 
been  exuded,  blackish  crust  capping  the  chancre  beneath; 


34        SYPHILIS  AND    THE    VENEREAL   DISEASES. 

the  "annular  chancre"  in  which  the  sclerotic  mass  forms 
a  ring  slightly  raised  above  the  level  of  the  centre  of  the 
infective  lesion;  the  "indurated  nodule,"  in  which  masses 
of  sclerotic  tissue,  varying  in  size  from  a  bird-shot  to  small 
pullet-egg-sized  masses,  develop  as  a  consequence  of  in- 
fection of  the  submucous  tissue  of  the  progenital  region, 
more  commonly  of  men ;  and  the  "  diffuse  infiltrating 
chancre"  (" infective  balano-posthitis  "  of  Mauriac),  which 
furnishes  a  species  of  thin  cuirass  over  the  mucous 
surface  of  the  glans  and  prepuce,  dull  red  or  at  times 
crimson-tinted.  The  induration  in  well-marked  cases  is 
distinct,  and  the  syphilitic  nature  of  the  process  is  dem- 
onstrated later  in  the  course  of  every  carefully  studied 
case. 

Mixed  Chancre. — By  this  term  is  generally  desig- 
nated a  venereal  lesion  which  at  the  outset,  usually  a 
brief  time  after  infection,  exhibits  all  the  characteristic 
features  of  the  soft  chancre  ("  chancroid,"  "  chancrelle," 
etc.),  but  which,  after  a  due  incubative  period  has  elapsed, 
becomes  specifically  indurated  at  the  base,  is  accom- 
panied by  syphilitic  bubo,  and  later  is  followed  by  gen- 
eral syphilis.  This  accidental  implantation  of  the  virus 
of  syphilis  upon  a  soft  chancre  (or  upon  its  site  before 
the  appearance  of  the  latter)  is  analogous  to  the  com- 
plication which  ensues  when  a  herpetic  vesicle  ("cold 
sore  ")  of  the  lip  or  a  cigarette-burn  of  the  same  region 
becomes  infected  with  the  virus  of  syphilis.  In  these 
cases  it  is  the  modification  of  the  original  process  that 
announces  the  syphilitic  complication. 

The  chancroid  or  "soft  chancre"  is  essentially  a 
pustular  lesion,  and  its  purulent  secretion,  whether  from 
pustule  or  from  suppurating  abrasion  or  fissure,  is  indef- 
initely auto-inoculable,  as  distinguished  from  the  secre- 
tion of  the  syphilitic  initial  lesion,  which  is  scanty  and 
non-auto-inoculable ;  hence  all  infecting  chancres  secret- 
ing an  auto-inoculable  pus  are  of  the  "mixed"  type. 
The  bubo,  also,  accompanying  the  soft  chancre  is  usually 
inflammatory  and  has  a  tendency  to  suppurate,  as  dis- 


ACQUIRED  SYPHILIS.  35 

tinguished  from  the  dense  multiple  buboes  of  syphilis, 
which  rarely  suppurate  and  are  often  non-inflammatory 
in  type.  It  follows,  then,  that  the  buboes  of  "  mixed 
chancre  "  may  exhibit  the  features  of  one  or  the  other 
of  the  two  disorders  thus  commingled.  The  important 
point  to  recognize  is  that  syphilis  may  ensue  after  the 
occurrence  of  "  mixed "  chancre ;  and  this  possibility 
should  never  be  forgotten  in  making  the  prognosis  of 
any  suspicious  venereal  sore.  The  individuals  most 
often  exhibiting  these  "  mixed  "  chancres  are  of  the  pau- 
per class  frequenting  public  dispensaries  and  out-patient 
departments  of  hospitals — persons  whose  female  asso- 
ciates are  as  uncleanly  as  they  are  vicious. 

Another  "  mixed  "  variety,  in  the  light  of  modern  sci- 
ence, is  the  chancre  of  syphilitic  origin  that  is  also  later 
infected  with  micro-organisms.  This  complication  is 
more  common  than  is  generally  supposed.  All  the  pus 
cocci,  several  of  the  mucors,  and  a  large  number  of  for- 
eign substances,  usually  inert,  may  often  be  recognized 
in  chancres,  especially  in  those  of  the  filthy,  but  also 
of  those  who  never  previously  suffered  from  venereal 
disease,  and  who,  in  ignorance  or  as  the  result  of  im- 
proper advice,  suffer  from  neglect  of  cleanliness  or  from 
positive  aggravation  of  the  original  disease. 

Chancres  of  the  Syphilized. — Persons  infected  with 
syphilis  have  usually  but  one  attack  in  a  lifetime.  The 
exceptions  to  this  rule  are  so  rare  as  simply  to  enhance 
its  value  and  importance.  But  the  recent  as  well  as  the 
veteran  victims  of  that  disease  expose  themselves  to  it 
and  to  other  venereal  diseases  with  results  which  de- 
mand exact  recognition. 

Such  persons,  of  course,  may  contract  "  soft  chancres." 
But  when  exposed  to  fresh  sources  of  syphilitic  virus 
they  occasionally  exhibit,  as  a  result,  chancres  of  a  for- 
midable type  and  an  obscure  character,  requiring  some 
expertness  for  their  proper  recognition.  Some  of  these 
results  are  (a)  lesions  like  soft  chancres,  but  atypical, 
less  clean-cut  at  the  edge,  with  much  less  purulent  secre- 


2)6        SYPHILIS  AXD    THE  VENEREAL  DISEASES. 

tion,  and  non-auto-inoculable ;  {b)  slightly  indurated 
chancres,  strongly  resembling  the  initial  erosion  chancre, 
without  accompanying  syphilitic  bubo,  and  disappearing 
without  leaving  results  of  consequence  ;  {c)  large  indura- 
tions with  deep  central  excavation,  at  times  strongly 
resembling  the  "  Hunterian  "  chancre,  yet  without  bubo, 
and  yielding  completely  to  proper  internal  treatment. 
Some  of  all  these  are,  without  question,  gummatous  (so- 
called  "  tertiary  ")  lesions  of  general  syphilis,  occurring 
with  reawakened  activity  where,  at  the  site  of  invasion, 
new  bacilli  have  been  introduced.  Yet  rarer  are  (d)  pea- 
sized  and  larger,  exceedingly  dense,  circumscribed  thick- 
enings of  the  genital  region,  without  erosion,  ulcer,  or 
hyperaemia,  and  due  to  the  causes  named  above. 

Location  of  Chancres. — As  distinguished  from  chan- 
croids, which  are  very  rarely  extra-genital  in  site, 
syphilitic  chancres  may  occur  upon  any  exposed  por- 
tion of  the  body-surface ;  very  rarely  indeed  do  they 
develop  at  long  distances  from  the  mucous  orifices  of 
the  body  (as,  for  example,  in  the  bladder,  oesophagus, 
stomach,  etc.).  The  genital  region  of  the  two  sexes  is 
most  often  involved  merely  because  of  the  frequency  of 
transmission  in  the  ample  opportunities  of  the  sexual 
act.  In  this  way  the  balano-preputial  sulcus,  the  rim 
and  inner  face  of  the  prepuce,  the  frsenum,  glans,  and 
integument  of  the  penis,  the  scrotum,  the  inner  face  of 
the  thigh  in  contact  with  the  latter,  and  the  perineum 
become  common  sites.  Urethral  chancres  are  rarely 
deeply  situated,  but  they  may  commonly  be  recognized 
at  the  tip  of  the  glans  in  men,  where  the  indurated  mass 
encroaching  upon  the  limits  of  distensibility  of  what 
may  be  termed  the  "  urethral  nozzle  "  produces  so  much 
local  irritation  and  consequent  sero-purulent  discharge 
that  the  symptoms  are  often  mistaken  for  those  of  a 
blennorrhagia.  When  the  glans  in  these  cases  is 
grasped  firmly  between  the  thumb  and  the  finger,  the 
induration  may  be  felt,  resembling  a  short  section  of  a 
clay  pipe    let    into   the    submucous    tissue,   and   at  the 


ACQUIRED   SYPHILIS.  37 

moment  of  pressure  a  characteristic  whitening  of  the 
rim  of  the  labia  of  the  meatus  urinarius  bears  witness  to 
the  extreme  thickening  of  the  initial  lesion. 

In  women  the  labia  majora  and  minora,  the  four- 
chette,  the  os  uteri,  the  clitoris,  the  vestibule,  the  meatus 
urinarius,  and,  very  rarely,  the  point  of  the  superior 
commissure  of  the  vulva  are  the  usual  sites  of  chancres. 
In  these  situations  their  transformation  in  situ  to  condy- 
lomata, mucous  patches,  and  other  secreting  lesions  of 
systemic  disease  is  readily  effected  in  consequence  of 
the  heat,  moisture,  and  friction  to  which  they  are  here 
exposed.  In  women  the  deformities  of  the  genital 
region,  venereal  in  origin,  are  commonly  of  exaggerated 
type,  and,  as  a  rule,  in  fetor,  in  abundance  of  secretion, 
and  in  volume  they  far  exceed  the  corresponding  lesions 
of  the  other  sex. 

Chancres  of  the  vagina  are  rare ;  when  they  occur 
they  usually  escape  observation.  They  are  probably 
more  common  than  is  set  down  in  the  statistics  of  the 
malady.  Chancres  of  the  mucous  envelope  of  the 
cervix  are  usually  visible  on  its  anterior  limb.  They  are 
reddish  or  empurpled  excoriations  with  an  engorged 
areola;  their  face  is  often  covered  with  a  pultaceous  and 
adherent  film.  In  the  genital  chancres  of  women  the 
inguinal  glands  usually  escape  involvement. 

Extra-genital  chancres  are  not  of  rare  occurrence  in 
the  larger  cities,  and,  as  already  pointed  out,  may  be 
recognized  in  every  region  of  the  body.  The  most 
frequent  sites  are  the  lips,  fingers,  nipples,  anus,  tonsils, 
tongue,  nares,  thighs,  arms,  and  toes.  They  result  from 
the  contacts  incidental  to  kissing,  sucking,  biting, 
vaccinating,  the  smoking  of  pipes,  the  nursing  of  chil- 
dren at  the  breast,  the  practices  of  sodomy,  digital 
explorations  and  operations  of  the  accoucheur,  physician, 
and  surgeon,  and  from  many  accidents  of  daily  life. 
They  belong,  without  exception,  to  the  types  of  chancre 
already  described,  invariably  following  periods  of  incu- 
bation,   occurring    with    well-marked    induration,    and 


38        SYPHILIS  AND    THE    VENEREAL   DISEASES. 

accompanied  by  adenopathy  of  the  glands  in  the  vicinity 
of  the  infected  part.  Some  are  densely  indurated  fis- 
sures (nipple,  anus,  lip) ;  some  are  indurated  dry  papules 
(as  after  vaccination,  biting,  tattooing) ;  some  are  flattish 
plaques  of  a  dull-red  hue,  or  ulcers  covered  with  an 
ashen  paste  (tonsils,  tongue,  uterus) ;  some  are  irregu- 
larly shaped  tumor-like  masses  (lips) ;  some,  finally,  are 
simply  symmetrical  ovoid  thickenings  of  normal  tissue 
(finger,  toe,  hang-nail,  etc.).  Chancres  of  the  anus  may 
be  found  an  inch  or  more  above  the  external  orifice.  In 
this  region  the  lesion  commonly  occurs  as  an  indurated 
fissure,  usually  less  painful  than  the  ordinary  fissures  of 
the  part. 

Number  of  Chancres. — The  initial  lesions  of  syphilis 
are  seldom  multiple ;  most  often  they  are  single.  If 
dual  in  number  or  more  numerous,  they  are,  as  a  rule, 
multiple  from  the  beginning.  In  these  cases  the  infer- 
ence is  just  that  there  has  been  a  simultaneous  acci- 
dental inoculation  of  all  such  points  at  a  given  moment. 
The  non-auto-inoculability  of  the  secretion  of  the  initial 
lesion  forbids  its  multiplication  upon  the  person  of  an 
individual  once  infected,  even  as  the  result  of  an  acci- 
dent. The  auto-inoculability  of  the  pus  of  the  "  soft 
chancre,"  on  the  contrary,  offers  abundant  opportu- 
nities for  its  spread  from  one  point  to  another  of  the 
subject  of  the  disease,  and  at  the  same  time  furnishes 
ample  supplies  for  infection  at  any  given  moment  in 
several  points  simultaneously.  It  follows  that  while  in 
exceptional  cases  a  patient  may  exhibit  at  one  time  two 
or  three  initial  lesions  of  syphilis  on  his  person,  he 
never  compares  in  multiplicity  of  chancres  with,  for 
example,  a  woman  whose  labial  sores  have  supplied  a 
pus  streaming  over  the  perineum  where  fifty,  and  even  a 
hundred  or  more,  soft  chancres  may  at  times  be 
counted. 

Induration  of  Chancres. — The  specific  induration  of 
the  initial  lesion  is  one  of  its  constant  features.  This 
sclerosis  is  recognized  by  the  sense  of  touch  in  varying 


ACQUIRED  SYPHILIS.  39 

degrees  as  a  distinctly  defined  thin  plate  or  sheet  of 
inelastic  tissue  let  in  beneath  the  excoriation,  ulcer,  etc., 
or  as  a  dense  mass  with  the  hardness  of  ivory  or  carti- 
lage, varying  in  size  from  a  split  pea  to  that  of  a  pullet's 
egg,  and  even  to  masses  still  larger.  At  times  the 
sclerosis  is  so  dense  as  to  suggest  the  hardness  of 
marble.  All  these  grades  of  induration  are  in  part 
correlated  to  the  degree  of  irritation  to  which,  after  its 
complete  evolution,  the  chancre  is  subjected.  The 
situation  of  the  chancre  is  a  factor  determining  in  part 
the  extent  of  the  induration,  as  chancres  of  the  vagina 
are  proverbially  less  indurated,  and  those  of  the  muco- 
cutaneous borders  (lips,  preputial  orifice,  etc.)  more 
conspicuously  sclerotic,  than  others.  The  induration 
may  precede  or  follow  (much  more  often  the  latter)  the 
evolution  of  the  chancre,  or  it  may  first  be  observed  at 
the  moment  of  detection  of  the  sore  itself.  The  very 
late  occurrence  of  induration  in  a  chancre  is  usually  a 
portent  of  good,  as  a  delay  of  from  twenty  to  thirty 
days  after  the  appearance  of  a  lesion  supposed  to  be  a 
precursor  of  syphilis  usually  negatives  the  expectation 
of  that  disease.  The  sclerosis  may  disappear  before  the 
healing  of  the  chancre,  or,  what  is  quite  common,  may 
persist  long  after  the  involution  of  the  latter,  and  even 
long  after  the  occurrence  of  general  symptoms.  Occa- 
sionally one  may  recognize  the  pigmented,  pigmentless, 
or  sclerotic,  keloid-like  relics  of  induration  six  months 
after  infection,  and  even  after  all  symptoms  of  general 
syphilis  have  for  the  time  disappeared.  Sooner  or  later 
the  induration  always  wholly  disappears,  and  for  the 
most  part  leaves  behind  it  no  traces  of  its  existence, 
these  facts  seeming  to  bear  no  relation  to  the  future  of 
the  patient.  The  so-called  "  relapsing  indurations  "  are 
usually  syphilomata,  evidences  of  general  syphilis,  so- 
called  "  tertiary  gummatous  infarctions  of  the  genital 
region." 

The  characteristic  sclerosis  or  induration  of  syphilitic 
chancres  should  not  be  confounded  with  inflammatory 


40        SYPHILIS  AND    THE    VENEREAL  DISEASES. 

oedema,  which  may  occur  beneath  or  about  any  genital 
lesions.  This  characteristic  sclerosis  may  develop  as  a 
complication  of  any  process,  as  a  result  of  the  applica- 
tion of  caustic  or  irritating  substances  to  the  part ;  or 
from  traumatism ;  from  lymphatic  obstruction  ;  or  from 
constricting  dressings,  as  when  a  rubber  band  is  tightly 
applied  around  the  penis  for  the  purpose  of  holding  lint 
in  contact  with  the  glans.  Inflammatory  oedema  is  usu- 
ally much  less  defined  in  contour  than  is  the  sclerosis  of 
a  chancre ;  it  is  softer,  and  never  possesses  the  dense 
firmness  of  the  latter.  Of  course,  as  a  result  of  irritation 
of  a  sufficient  grade,  the  sclerosis  of  a  chancre  may 
itself  be  complicated  by  an  inflammatory  oedema  which 
may  surround  or  embrace  the  dense  new-formation  of 
the  sclerotic  mass. 

The  "relapsing  indurations"  {chancre  redux ;  pseudo- 
chancre  indure)  described  by  some  authors  are  rarely 
true  relapses  of  the  characteristic  primary  sclerosis  of 
the  syphilitic  chancre.  Some  are  without  question  early 
or  late  gummatous  deposits  of  constitutional  syphilis 
occurring  in  the  genital  region ;  some  are  the  result  of 
re-exposure  of  the  syphilitic  subject  to  a  fresh  virus 
which  serves  to  relight  the  original  process  at  or  near 
the  original  point  of  infection ;  some  are  engorged 
lesions  of  a  non-syphilitic  character,  treated  by  caustic 
applications.  They  may  be  superficial  or  deep,  as  small 
as  split  peas  or  as  large  as  walnuts.  They  are,  as  a  rule, 
less  amenable  to  treatment  than  the  first  sclerosis  of  the 
chancre. 

The  Portent  of  Chancres. — While  it  is  true  that 
every  initial  lesion  of  syphilis  signifies  that  a  syphilis, 
mild  or  grave,  will  ensue,  it  does  not  follow  that  from 
the  number  or  the  appearance  of  chancres  a  prognosis 
may  be  made  as  to  the  severity  or  the  reverse  of  the 
ensuing  disease.  An  exceedingly  insignificant  looking 
ham-colored  spot  in  one  individual  may  be  followed  by 
the  most  malignant  form  of  the  disease,  and  may  lead  to 
u  syphilis  of  the  second  generation  that  may  destroy  in 


ACQUIRED  SYPHILIS.  4 1 

succession  the  fruits  of  a  wife's  pregnancies ;  while  a 
group  of  three  gigantic  masses  of  sclerosis,  each  with 
excavations  of  an  ulcerative  type,  may  be  followed  by 
even  meagre  results.  The  reason  for  this  disproportion 
may  be  found,  as  some  allege,  in  the  activity  of  the 
germs  present,  but  it  is  more  probably  due  to  the  kind 
of  soil  in  which  those  germs  are  implanted. 

Duration  of  Chancres. — Chancres  may  persist  until 
the  evolution  of  systemic  syphilis.  They  may,  however, 
be  resolved  and  disappear  almost  wholly  at  an  earlier 
date.  When  persisting  still  later,  they  are  always 
changed  to  conform  to  the  type  of  the  general  symp- 
toms of  the  disease,  and  are  in  reality  no  longer 
chancres,  but  condylomata,  granulating  mucous  patches, 
gummata,  etc.  When  persisting  to  such  a  late  stage, 
they  usually  announce  the  fact  by  significant  changes, 
such  as  elevation  of  the  surface,  tumefaction  of  the 
mass,  softening  of  the  sclerosis  wholly  or  in  part,  and 
hypersecretion. 

Termination. — Chancres  may  terminate  by  complete 
resolution.  However  numerous  and  formidable  in 
appearance,  they  rarely  result  in  any  mutilation  of  the 
part  in  which  they  have  been  seated.  The  simplest 
lingering  traces  of  their  existence  are  either  moderately 
pigmented  patches,  such  as  occur  on  the  skin  of  the 
penis  in  young  subjects  with  very  dark  hair  and  eyes, 
or,  as  a  sequence  of  such  pigmentations  in  that  class 
of  individuals,  even  non-pigmented  plaques  as  large  as 
the  original  chancre,  being,  in  fact,  pigmented  spots 
whence  the  pigment  has  slowly  been  removed.  Chan- 
cres seldom  leave  scars,  for  the  reason  already  given, 
namely,  their  indisposition  to  undergo  ulceration.  In 
this  respect  they  are  strongly  distinguished  from  soft 
chancres,  which,  as  a  rule,  suppurate  and  ulcerate,  and 
often  leave  punched-out  scars  as  relics  of  their  ravages. 
When  syphilitic  chancres  actually  leave  scars,  these  are 
always  the  result  of  ulceration,  and  this  ulceration  is  the 
fruit    of    some    accidental    complication    of    the     local 


42         SYPHILIS  AND    THE  VENEREAL  DISEASES. 

disease.  Thus,  the  chancre  of  the  urethra  lies  just 
where  the  stream  of  urine  several  times  in  the  day 
necessarily  passes  over  its  entire  face,  and,  this  fluid 
being  in  a  high  degree  irritating  in  consequence  of  the 
urinary  salts  it  contains,  the  chancre  often  secretes  quite 
freely,  and  may  leave  an  odd-looking  scar  at  the  tip  of 
the  glans  penis,  this  organ,  after  all  is  healed,  looking  as 
though  it  had  lost  its  apex,  while  the  external  urinary 
meatus  has  for  a  distance  of  perhaps  half  an  inch  or 
more  a  "  reamed-out "  aspect.  Deeply-cauterized  and 
filthy  chancres,  as  well  as  those  of  "  mixed  "  type,  may 
leave  small  cicatrices.  It  follows  that  in  making  exami- 
nations for  the  army  and  navy  and  for  life  insurance,  the 
non-discovery  of  scars  upon  the  progenital  region  of 
men  does  not  prove  that  they  have  not  had  a  preceding 
syphilis,  and  the  actual  discovery  of  such  scars  in  the 
progenital  region  is  by  no  means  conclusive  that  the 
subjects  of  the  same  have  been  syphilitic. 

Diagnosis. — The  diagnosis  of  the  initial  lesion  of 
syphilis  is  made  chiefly  by  a  careful  study  of  the  symp- 
toms already  detailed.  By  the  recognition  of  these 
special  characters,  rather  than  by  the  exclusion  of  the 
symptoms  of  other  diseases,  is  the  end  best  reached. 

The  chancroid  or  "  soft  chancre  "  is  usually  a  pustular 
lesion,  and  is  represented  either  by  an  unbroken  pustule 
surmounting  its  characteristic  sharply-cut  ulcer,  or,  after 
the  rupture  of  the  pustule,  by  the  pus-bathed  ulcer  itself, 
circular,  oval,  stellate,  or  linear  in  outline.  However 
engorged  its  base,  the  latter  is  never  indurated  save  in 
the  "  mixed  "  variety.  There  is  no  period  of  incubation, 
and,  though  at  times  single,  the  lesions  are  usually 
multiple  and  often  exceedingly  numerous,  scores  form- 
ing in  extreme  cases.  The  adenopathy  of  chancroid  is 
represented  usually  by  a  single  though  occasionally  by 
a  double  bubo.  Rarely  many  buboes  occur  of  a  dis- 
tinctly inflammatory  type,  with  a  tendency  to  suppura- 
tion and  the  production  in  the  lips  of  the  wound,  when 
there  is  spontaneous  bursting  of   the  gland-abscess,  of  a 


ACQUIRED   SYPHILIS.  43 

chancroid  by  secondary  infection.  The  purulent  secre- 
tion of  the  chancroid  is  practically  indefinitely  auto- 
inoculable — a  fact  accounting  for  the  multiplicity  of  the 
lesions  in  many  cases.  Chancroids  are  usually  genital 
in  situation ;  rarely  are  they  extra-genital,  with  the 
exception,  particularly  in  filthy  women,  of  the  anus. 
The  floor  of  the  chancroidal  ulcer  is  usually  covered 
with  a  more  or  less  tenacious  slough  resembling  wet 
chamois-skin,  and  presenting  in  this  particular  a  marked 
contrast  with  the  shallow,  scantily  secreting,  indurated, 
and  sloping  edges  and  floor  of  the  initial  lesion  of 
syphilis.  Lastly,  the  accidents  of  sloughing,  phagedena, 
and  enormous  involvement  of  the  skin  and  the  subcu- 
taneous tissues  of  the  thigh  in  ulcerative  and  burrowing 
sinuses  are  almost  unknown  in  syphilis  of  the  cleanly, 
and  are  by  no  means  of  very  rare  occurrence  in  chan- 
croids of  all  classes  of  patients. 

The  lesions  of  herpes  progenitalis  are  very  readily 
differentiated  from  syphilitic  chancres.  The  former  are 
transitory,  lasting  at  the  longest  for  but  a  few  days — a 
feature  of  prime  importance  in  establishing  a  diagnosis, 
for  any  so-called  "  herpetic  lesions  "  followed  by  ulcers 
lasting  for  ten  days  are  probably  not  such,  and  should 
be  viewed  with  great  suspicion.  Herpetic  lesions  in  the 
progenital  region  are  essentially  vesicular,  and  are  visi- 
ble either  as  vesicles  or  as  the  relics  of  vesicles  in  the 
form  of  very  superficial  reddish  plaques,  where  delicate 
and  lightly-tinted  crusts  appear,  or  as  slightly  raw  and 
tender,  finger-nail-sized  spots,  furnishing  a  serum  suffi- 
cient in  quantity  to  moisten  an  applied  bit  of  cotton. 
Their  cause,  further,  may  often  be  determined  without 
great  difficulty  (venery,  pollutions,  gastro-intestinal  de- 
rangements such  as  constipation,  chills,  gouty  attacks, 
etc.). 

Balanitis. — In  this  affection,  as  in  herpes  progenitalis, 
the  disease,  as  distinguished  from  all  varieties  of  chancre, 
is  always  short-lived  and  yields  readily  to  treatment.  In 
typical  lesions  the  mucous  membrane  of  the  sac  of  the 


44         SYPHILIS  AND    THE  VENEREAL   DISEASES. 

prepuce  and  of  the  glans  penis  becomes  reddened,  tumid, 
and  in  extreme  cases  of  a  deep  purplish  hue,  with  super- 
ficial excoriations  of  the  external  layer  of  the  membrane 
in  plate-like,  finger-nail-sized  plaques,  which  can  be 
studied  best  in  a  well-marked  case  of  blennorrhagia  of 
the  conjunctival  membrane.  There  are  distinct  sensa- 
tions of  itching  and  burning  in  the  part,  and  the  odor 
of  the  secretions  is  usually  nauseous  in  consequence  of 
the  altered  character,  in  this  part,  of  the  secretion  from 
the  glands  of  Tyson.  There  is  no  induration,  no  gland- 
ular complication,  and  never  ulceration.  The  disorder 
is  usually  relieved,  when  not  complicated,  in  the  course 
of  a  few  days  by  the  application  of  a  stimulating  vinous 
lotion  aided  by  astringents,  a  thin  layer  of  absorbent 
cotton  being  interposed  between  the  two  folds  of  mem- 
brane in  contact. 

Verruca  Acuminata  ("  Venereal  warts,"  Moist  warts, 
Condylomata,  etc.). — Filiform,  papilliform,  single  or  mul- 
tiple, often  numerous,  vegetations  may  develop,  for  the 
most  part  in  the  progenital  region  of  the  two  sexes. 
These  warty  growths  are  usually  pedunculated,  but  at 
times  are  flattened.  They  secrete  a  mucoid  fluid  of 
offensive  odor ;  this  fluid  in  syphilitic  subjects  is  highly 
contagious.  The  growths  vary  in  size  from  a  pin-head 
to  compound  masses  as  large  as  the  fist  and  even  larger. 
As  distinguished  from  chancres,  they  are  never  indu- 
rated, they  rarely  ulcerate,  they  are  not  accompanied  by 
adenopathy,  and  they  survive  for  periods  of  time  far  out- 
lasting the  life-history  of  even  persistent  initial  lesions  of 
syphilis.  They  may  occur  in  virgins,  but  they  are  more 
common  in  the  subjects  of  venereal  disorders,  as  also  in 
those  suffering  from  leucorrhceal  and  other  pathological 
fluids  bathing  the  genital  region.  Rarely  they  have  an 
extra-genital  site,  such  as  the  face.  In  males  they  are 
apt  to  form  in  the  sulcus  behind  the  corona  glandis, 
about  the  frsenum,  in  the  external  orifice  of  the  urethra, 
and  over  the  scrotum;  in  women,  chiefly  about  the  four- 
chette  and  the  labia.     They  are  readily  recognized  by 


ACQUIRED  SYPHILIS.  45 

their  resemblance  to  the  comb  of  a  cock,  by  the  absence 
of  ulceration  and  of  induration  of  the  base,  and,  when 
wiped  clean,  by  their  florid  aspect  and  their  readiness  to 
bleed  when  scraped  or  cut  away. 

Epithelioma  of  the  genital  organs  occurs  most  com- 
monly after  the  middle  periods  of  life  in  both  sexes — 
ages  when  chancres  are  decidedly  of  less  frequent  occur- 
rence than  at  others.  In  men  the  most  frequent  site  of 
the  disease  is  the  glans  penis,  where  a  circumscribed, 
flattened  papule,  verrucous  elevation,  or  shallow  erosion 
may  occur.  The  period  of  duration  of  these  lesions  is 
for  most  cases  far  greater  than  that  of  either  chancre  or 
gumma.  The  base  of  one  or  two  of  these  primary 
growths  may  become  indurated  and  the  neighboring 
glands  may  enlarge ;  but  the  inactive,  often  slightly 
hemorrhagic  or  crusted  papule  or  warty  growth  seated 
upon  an  infiltrated  tissue,  with  an  ulcer  forming  only 
after  a  long  evolution  of  the  primary  symptom  of  the 
disease,  is  not  to  be  mistaken  for  a  chancrous  lesion. 
When  actually  ulcerating,  the  resulting  ulcer  is  of  the 
type  of  the  epitheliomata  of  the  skin  in  general,  with 
serous,  'scanty,  or  bloody  secretion,  everted  edges,  and 
excavated,  often  eroded,  floor.  For  women  the  region 
of  preference  in  the  progenital  forms  is  the  clitoris, 
where  the  lesions  above  described  may  occur  occasion- 
ally with  striking  deformity  of  the  parts*  The  non- 
inflammatory, often  scarcely  colored  thickenings,  ero- 
sions, warty  growths,  etc.  of  both  labia  and  clitoris,  in 
women  past  the  menopause,  are  all  to  be  separated  from 
chancrous  changes. 

Molluscum  epitheliale  of  the  genital  region  in  young 
persons,  especially  those  of  the  male  sex,  is  characterized 
by  the  occurrence,  on  the  scrotum  chiefly,  of  split-pea- 
sized,  yellowish-white,  waxy-looking,  and  imbedded  or 
projecting  bodies,  usually  exhibiting  at  one  point  or 
another  of  their  globular  surface  a  whitish  or  blackish 
punctum  representing  the  occluded  orifice  of  a  sebaceous 
gland.     They  may  be  few  in  number,  but  often  they  are 


46        SYPHILIS  AND    THE  VENEREAL  DISEASES. 

exceedingly  numerous,  studding  the  region  affected  with 
isolated  but  closely  approximated  lesions.  They  are 
never  ulcerated,  indurated,  inflammatory,  nor  the  seat 
of  evidence  of  any  acute  process.  It  is  impossible  for 
the  trained  physician  to  mistake  them  for  chancres,  but 
the  error  is  occasionally  made  by  young  and  timid  lay 
patients,  who,  having  for  good  reasons  become  anxious 
about  exposure  to  disease  of  the  affected  part,  discover  for 
the  first  time,  on  careful  scrutiny,  the  molluscous  bodies, 
and  are  filled  with  terror  at  the  sight.  There  is  never  any 
glandular  complication  of  these  simple  lesions,  and  in  any 
doubtful  case  the  expression  of  the  cheesy  mass  from 
the  orifice  of  the  gland  would  establish  the  diagnosis. 

Lichen  planus  of  the  genital  region,  particularly  in  the 
male  sex,  is  at  times  liable  to  be  mistaken  for  chancre. 
But  the  lesions  are  always  papular,  dry,  and  flattened  at 
the  apex,  with  a  singularly  characteristic  polygonal  out- 
line, often  very  sharply  defined.  They  are  never  seated 
on  an  indurated  base,  are  not  accompanied  by  glandular 
enlargement,  are  not  eroded  nor  ulcerated,  and  are 
usually  multiple,  with  at  times  marked  invasion  of  the 
skin  of  the  lower  belly  and  the  adjacent  region  of  the 
thighs.  An  interesting  feature  of  lichen  planus  of  the 
genital  region  is  the  grouping  of  the  lesions  in  lines,  so 
that  at  times  half  a  dozen  or  more  of  the  small  crimson, 
reddish,  purplish,  or  dull  leaden-hued  papules  stretch  in 
a  direct  line  from  one  point  to  another  over  the  dorsum 
of  the  glans  penis,  in  the  skin  of  the  organ.  Angular 
as  well  as  rectilinear  figures,  and  even  odd-looking 
cockades,  may  thus  be  formed.  Lichen  planus  lesions 
of  the  genital  region  are  often  the  seat  of  intense  itch- 
ing, and  may  be  well  scratched  with  the  evidences  of 
such  traumatism  upon  and  about  them.  They  com- 
monly persist  for  a  period  of  time  much  longer  than 
that  limiting  the  continuance  of  chancres.  The  usual 
occurrence  of  typical  lesions  elsewhere  than  in  the  geni- 
tal region  (forearms,  abdomen,  thighs)  is  of  value  in 
establishing  a  correct  diagnosis. 


ACQUIRED  SYPHILIS.  47 

Psoriasis  of  the  genital  regio?i  is  exposed  in  well- 
defined  disks  covered,  as  a  rule,  with  large-sized  lami- 
nated scales,  the  disks  varying  in  size  from  a  pin's  head 
to  that  of  a  silver  dollar  and  even  larger.  They  occur 
upon  the  skin  of  the  penis  and  the  scrotum,  with  fre- 
quent involvement  of  the  pubic  region,  lingering  near  the 
line  of  the  hair  and  projecting  beyond  the  latter  upward 
and  downward.  The  absence  of  secretion,  of  induration, 
of  ulceration,  and  of  glandular  complication,  and  the 
frequent  presence  of  the  disease  in  other  regions  of  the 
body,  suffice  to  determine  its  character. 

The  late  gummatous  ("  tertiary"}  lesions  of  general 
syphilis  occurring  in  the  genital  region  are  exceedingly 
liable  to  be  mistaken  for  chancres.  Here  the  diagnosis 
rests  upon  the  discovery,  elsewhere  upon  the  person,  of 
the  relics  of  a  preceding  syphilis,  the  frequently  obtain- 
able history  of  such  a  disease,  the  well-marked  tendency 
of  the  late  deposits  of  syphilis  to  ulcerate  and  spread  by 
serpiginous  destruction  of  the  tissue  involved  (a  rare 
complication  of  infecting  chancres),  and  often  upon  a 
history  of  persistence  of  the  gummatous  thickening  or 
ulceration  for  a  time  longer  than  that  required  for  the 
fullest  evolution  of  both  chancre  and  general  consecu- 
tive syphilis.  The  chancres  of  the  syphilized,  previously 
described,  are  often  illustrations  of  this  singular  process, 
suggesting  the  origin  of  the  mucous  patch  in  the  mouth 
of  the  tobacco-chewer,  and  in  doubtful  cases  only  the 
most  careful  study  will  suffice  to  distinguish  between  the 
two.1 

Pathological  Anatomy  of  Chancres. — As  the  syphi- 
litic chancre  is  like  and  unlike  all  other  cutaneous  and 
mucous  lesions,  and  as  the  eruptions  of  syphilis  are  like 
and  unlike  all  cutaneous  affections,  so  the  minute 
anatomy  of  chancres  resembles  that  of  many  other 
pathological   formations.      Under   the   microscope    one 

1  For  a  tabulated  summary  of  the  diagnostic  differences  between  chan- 
cre and  other  genital  lesions,  consult  the  section  devoted  to  the  subject 
of  Chancroid. 


48         SYPHILIS  AND    THE  VENEREAL   DISEASES. 

finds  granulation-cells  within  reticulated  fibrous  meshes, 
and  cell-infiltration  partially  or  wholly  blocking  up  the 
lumen  of  the  vessels.  Where  erosions  have  occurred, 
naturally  the  epidermis  is  in  various  degrees  removed, 
and  the  papillae,  with  little  or  none  of  the  rete  left,  are 
exposed  or  are  even  in  great  part  removed.  The 
characteristic  induration  of  the  chancre  is  due  in  part  to 
new-formed  connective  tissue  and  in  part  to  epidermal 
thickening.  It  is  highly  probable,  however,  that  the 
lymph  of  the  part  is  profoundly  affected  by  a  special 
ferment  produced  by  the  bacilli  responsible  for  the 
disease,  when  the  latter  first  multiply  in  exterior  regions 
of  the  body.  The  absence  of  dense  induration  of 
chancres  of  the  vagina  and  the  cervix  points  conclu- 
sively to  the  fact  that  induration  is  a  condition  of  site 
rather  than  of  infarcted  vessel  or  of  multiplying  connec- 
tive-tissue fibres ;  and  the  extreme  indurations  seen  at 
the  muco-cutaneous  margins  of  the  body  point  equally 
to  the  action  in  those  regions  of  a  special  influence  upon 
the  effective  germs  of  the  disease. 

Treatment  of  Chancre. — Persistent  efforts  have  been 
made  from  time  to  time  to  set  aside  the  possibility  of 
syphilis  following  chancre  by  the  radical  destruction  of 
the  latter.  The  reasonableness  of  success  in  these 
efforts  is  on  a  priori  grounds  so  great  that  in  all  proba- 
bility they  will  never  be  abandoned  wholly,  but  the 
actual  results  have  thus  far  been  disappointing  and,  for 
reasons  that  need  not  here  be  set  forth,  are  enveloped 
in  considerable  doubt.  The  destruction  of  chancres  by 
chemical  agents  and  by  the  actual  cautery  has  repeat- 
edly failed  not  only  to  relieve  the  local  symptoms,  but 
also  to  prevent  the  occurrence  of  general  symptoms. 
The  same  may  be  said  of  total  excision  of  the  primary 
lesion,  and  even  of  total  excision  of  both  primary  sore 
and  all  the  glands  in  the  neighborhood  involved  in  the 
disease.  When  the  chancre,  as  is  usual  after  cauteriza- 
tion, exhibits  increased  induration  of  its  base,  even 
though  it  may  not  be  affirmed  that  the  ensuing  disease 


ACQUIRED   SYPHILIS.  49 

is  the  graver  for  the  complication,  it  is  certainly  true 
that  the  chancre  is  less  manageable  than  before.  In 
some  cases  exceedingly  grave  destructive  ulceration 
following  gummatous  deposits  has  occurred  in  patients 
where  these  attempts  have  been  made  with  all  possible 
precautions  to  jugulate  the  disease  in  sound  men.  In 
this  connection  it  must  not  be  forgotten  that  even 
experts  may  be  deceived  in  the  recognition  of  both  the 
chancres  of  syphilis. and  the  lesions  closely  resembling 
the  latter;  and  this  possibility  of  error  should  not  be 
ignored  by  the  practitioner  who  is  reasonably  judicious. 
There  is  still  a  division  among  authorities  on  the  ques- 
tion whether  the  initial  sore  is  merely  a  local  point  from 
which,  after  sufficient  multiplication,  the  microbe  of  the 
disease  or  its  toxine  is  swept  through  the  general 
economy,  or  whether  the  chancre  is  the  local  expression 
of  an  intoxication  generalized  at  the  outset. 

All  chancres  should  be  treated  by  strict  observance 
of  the  requirements  of  hygiene.  The  affected  part 
should  be  cleansed  with  warm  water  and  soap,  after 
which  washings  in  hot  borated  solutions  should  be 
employed.  In  the  event  of  tenderness  or  pain,  as  in 
the  case  of  chancres  of  the  pendulous  portion  of  the 
penis,  the  part,  when  practicable,  may  be  immersed  in 
hot  solutions  of  boric  acid  often  each  day,  or  even  in 
extreme  cases  for  hours  at  a  time.  After  drying,  the 
chancre  should  be  well  dusted  with  powder,  such  as 
boric  acid  (or  boric  acid  and  talc,  I  part  to  4,  when  the 
acid  itself  is  at  all  irritating),  europhen,  aristol,  hydro- 
naphthol  (1  part  to  100  of  fuller's  earth),  calomel  (or  1 
part  of  the  latter  to  3  or  4  parts  of  starch),  or  iodoform 
when  the  odor  of  the  drug  can  be  tolerated,  and  especially 
in  the  case  of  painful,  intractable,  or  irritable  chancres 

Beside  the  powders  named  above,  a  long  list  of  substances 
have  been  employed,  few  of  which  possess  any  advantages 
over  europhen,  iodoform,  and  calomel.     In  this  list  occur 
the  following  medicaments  :  iodol,  di-iodoform,  antifebrin 
salol,  sulfaminol,  sozo-iodol,  loretin,  bismuth,  subgallate. 


50         SYPHILIS  AND    THE   VENEREAL   DISEASES. 

When  erosions  form,  having  a  raw,  reddish,  slightly 
secreting  surface,  and  also  when  ulceration  occurs,  it  is 
generally  well  to  paint  the  surface  of  the  sore,  after  the 
washing  and  before  the  application  of  the  powder,  with 
a  solution  containing  from  I  to  2  grains  of  the  bichloride 
of  mercury  in  the  tincture  of  benzoin.  The  drying,  over 
the  eroded  surface,  of  the  gum  thus  medicated  is  usually 
not  unpleasant  to  the  subject  of  the  disease,  and  is  also 
cleanly,  protective,  and  efficient  as  a  parasiticide.  A 
valuable,  painless,  and  highly  effective  application,  even 
to  painful  chancres,  is  the  daily  painting  of  the  entire 
surface  with  a  saturated  aqueous  solution  of  pyoktanin 
blue,  the  sole  objection  to  which  is  the  staining  of  the 
clothing  which  may  result.  Formaline  (40  per  cent,  of 
formalhydehyde)  in  watery  solution  of  the  strength  of 
from  one-tenth  of  one  per  cent,  to  two  per  cent,  is  an 
effective  but  rather  more  painful  lotion.  After  all 
applications  have  been  made,  the  surface,  when  prac- 
ticable, should  be  guarded  from  contact  with  neighbor- 
ing parts,  not  with  a  view  to  the  prevention  of  auto- 
infection  (which  in  these  cases  is  not  to  be  feared),  but 
in  order  to  set  aside  the  possibility,  always  great,  of 
irritation  of  the  sore.  In  the  instance  of  chancres  which 
may  be  by  this  means  sufficiently  well  dressed  (sac  of 
the  prepuce,  frsenum,  etc.),  when  practicable,  it  is  well  to 
draw  the  foreskin  well  over  the  interposed  lint.  As  a 
rule,  when  chancres  are  large  and  tender  the  male  organ 
should  be  wrapped  in  a  thick  jacket  of  mercurialized 
wool  and  be  brought  up  in  the  line  of  Poupart's  liga- 
ment before  the  clothing  is  readjusted.  The  "jock- 
strap "  employed  by  bicycle  riders  may  be  worn  over 
any  lint  applied  to  the  male  genital  region,  as  both  penis 
and  testes  are  well  supported  in  its  embrace.  A  substi- 
tute for  it  may  be  found  in  a  pair  of  cotton  or  linen 
swimming  trunks  when  it  is  desired  to  protect  the  un- 
derclothing from  discharges.  Elastic  or  other  ligatures 
should  never  be  fastened  about  the  penis. 

In  women   the  labia,  when  similarly  affected,  should 


ACQUIRED   SYPHILIS.  5  I 

be  separated  by  antiseptic  cotton,  and  for  chancres  of 
the  cervix  pledgets  of  lint,  after  dressing  the  part, 
should  be  pushed  against  the  os  with  tampon  supports. 
For  these  chancres  both  the  pyoktanin  blue  and  the 
mercurialized  benzoin  lotions  are  excellent  applications. 
Lotions  often  useful  when  chancres  prove  irritable  under 
other  treatment  are  the  ordinary  black-wash,  pure  or 
diluted,  and  applied  by  the  aid  of  moistened  pledgets  of 
lint ;  tannic  acid  and  red  wine,  I  part  of  the  former  to  30 
of  the  latter;  in  some  cases  the  lead-and-opium  wash. 
As  a  rule,  all  salves  and  unguents  are  to  be  discarded  in 
the  management  of  chancres.  The  chief  exception  to 
the  rule  is  furnished  by  lesions  which  secrete  a  fluid 
gluing  the  dressing  so  tightly  to  the  part  that  when  the 
lint  which  has  been  applied  is  removed  no  little  pain  is 
experienced  and  slight  hemorrhage  ensues.  In  this 
event,  after  the  applications  described  above,  the  sore 
should  be  dusted,  and  then  there  should  be  applied  lint 
on  one  face  of  which  (that  next  the  chancre)  has  been 
smeared  carbolized  vaseline. 

In  the  management  of  chancres  of  the  urethral  orifice 
a  bit  of  medicated  lint  may  be  introduced  into  the  gaping 
orifice  if  required ;  but  the  most  important  of  the  meas- 
ures to  be  followed  is  the  immersion  of  the  penis,  when- 
ever practicable,  in  a  basin  of  warm  water  at  the  time  of 
each  urination,  as  by  this  means  the  urine  is  in  a  measure 
diluted  at  the  time  of  its  traversing  the  sore.  Weak  solu- 
tions of  the  nitrate  of  silver,  employed  not  as  a  caustic 
agent,  but  with  a  view  of  making  a  satisfactory  dressing 
of  an  eroded  surface,  may  also  at  times  be  used  with 
advantage. 

The  question  whether  the  treatment  of  syphilis  should 
be  begun  at  the  date  of  recognition  of  the  chancre  or  at 
the  time  of  the  appearance  of  symptoms  of  general 
syphilis  is  considered  elsewhere.  Internal  medication, 
however,  of  a  patient  affected  with  a  chancre  which  has 
been  recognized  as  indubitably  an  initial  lesion  of  syphi- 
lis   is  by  no  means    necessarily  the    treatment  of    that 


52         SYPHILIS  AND    THE  VENEREAL   DISEASES. 

syphilis.  Infecting  chancres  are  peculiarly  responsive  to 
a  properly-directed  treatment  by  internal  medicine,  and 
the  refusal  to  employ  the  latter  is  unwarranted  when  the 
diagnosis  is  practically  assured  and  the  lesions  are  either 
painful,  portentous,  or  the  source,  as  is  often  the  case, 
of  much  mental,  distress  to  the  patient.  Mercury  by 
the  mouth  is  in  these  cases  the  one  efficient  remedy. 
It  should  not  be  ordered  unless  the  diagnosis  is  satis- 
factorily established.  In  the  majority  of  all  cases  com- 
ing under  the  management  of  experts  the  diagnosis  is 
practically  ensured  from  the  first,  either  as  the  result 
of  confrontation  (discovery,  in  the  person  from  whom 
infection  was  received,  of  lesions  capable  of  conveying 
the  disease)  or  of  the  recognition  of  classical  features 
of  an  initial  sclerosis  in  the  person  acquiring  the  sore. 

It  should  not  be  forgotten,  then,  that  the  mercurial 
treatment  of  this  period  is  a  treatment  directed  to  the 
chancre,  and  not  to  the  as  yet  undeveloped  disease  to 
which  the  chancre  points.  If  this  be  borne  in  mind, 
the  end  is  readily  reached.  The  metal  should  be  used 
or  disused,  pushed  to  a  higher  dose  or  reduced  in  the 
quantity  administered,  according  as  resolution  of  the 
sclerosis  is  announced,  the  erosion  begins  to  heal,  and 
the  affected  part  to  assume  its  normal  character  as  to 
size,  color,  and  freedom  from  obvious  lesions. 

The  preparations  employed  are  those  useful  in  the 
general  management  of  syphilis,  to  which  reference  may 
be  made.  The  protoiodide  of  mercury  in  doses  of  from 
^  to  I  grain,  calomel  in  doses  of  from  ^  to  \  grain, 
gray  powder,  the  bichloride  (less  preferable  for  this 
special  purpose,  as,  in  the  doses  ordinarily  well  tolerated, 
its  operation  is  slower),  and  the  biniodide  may  each  be 
employed.  In  all  cases  of  anaemic  patients  the  hygienic 
and  tonic  remedies  useful  in  the  management  of  general 
syphilis  should  regularly  be  employed. 

"  Mixed "  chancres  do  not  call  for  destruction  by 
cauterization.  They  are  often  tender  and  painful,  and  in 
these  cases  much  trouble  may  be  avoided  by  early  and 


ACQUIRED   SYPHILIS.  53 

persistent  use  of  the  hot  borated  immersions  and  wash- 
ings described  above. 

Adenopathy;  Syphilitic  Bubo;  Lymphangitis. 

Adenopathy. — One  of  the  invariable  syndromes  of 
the  chancre  of  syphilis  is  a  characteristic  involvement  of 
the  lymphatic  glands  or  vessels,  or  both,  in  anatomical 
vicinity  to  the  site  of  infection.  These  changes  may 
become  perceptible  to  the  eye  and  the  touch  between 
the  fifth  and  the  tenth  day  after  the  recognition  of 
the  primary  sclerosis,  but  they  may  be  deferred  to  a 
fortnight,  and  in  rare  cases  even  to  longer  periods. 
As  a  rule,  these  changes  are  perceptible  in  the  glands 
or  vessels  on  the  same  side  of  the  body  as  that  of  the 
chancre ;  in  other  cases  the  nearer  side  is  spared  and 
the  opposite  side  is  involved.  This  results  from  the  in- 
terlacing of  the  lymphatic  vessels  in  the  median  line  of 
the  body.  In  yet  other  cases  both  sides  are  extensively 
involved,  so  that  it  would  seem  that  all  the  glands  and 
vessels  participate  in  the  morbid  process. 

When  the  glands  are  solely  or  chiefly  implicated,  the 
syphilitic  bubo  is  formed.  This  term  is  applied  to 
usually  multiple,  firm,  and  at  times  densely  indurated 
nodules,  small-nut  to  egg-sized,  each  representing  an  in- 
dolently enlarged  lymphatic  gland,  sometimes  grouped 
together  so  as  to  form  what  has  been  described  by  the 
French  as  a  "pleiad,"  where  one  which  is  predominantly 
affected  may  be  surrounded  by  "  satellites  "  of  smaller 
dimensions.  The  glands  are  usually  readily  distinguish- 
able the  one  from  the  other,  and  freely  movable  upon 
the  subjacent  tissues.  They  are  rarely  tender  or  painful, 
and  seldom  the  seat  of  an  acute  inflammation.  They 
are  covered  by  an  unaltered  integument,  and  are  occa- 
sionally merged  by  a  plastic  process  into  a  single  dense, 
smooth,  ovoid,  or  globular  mass  as  large  as  a  small 
orange.  Resolution  of  such  masses  under  treatment  or 
spontaneously  usually  reveals  the  component  members 
of  the  elements  of  the  tumor. 


54         SYPHILIS  AND    THE   VENEREAL   DLSEASES. 

The  course  of  these  ganglionic  enlargements  is,  as  a 
rule,  toward  a  gradual  resolution,  accomplished  fully  in 
the  course  of  six  or  eight  months,  rarely  requiring  a 
year.  As  a  rule,  involution  proceeds  to  a  favorable 
termination  in  the  course  of  a  month,  especially  when 
mercury  has  been  administered  in  the  treatment  of  the 
disease.  Suppuration  is  of  very  rare  occurrence,  due  in 
part  to  the  fact  of  the  absence  of  inflammatory  symptoms 
and  of  pyogenic  micro-organisms  in  the  infecting  chancre. 
When  such  accidents  occur,  the  cause  is  generally  to  be 
sought  in  the  field  of  the  chancre  (caustic  applications, 
filth,  imprisonment  beneath  a  prepuce  in  a  state  of  irre- 
ducible phimosis,  etc.),  and  the  subsequent  career  of  the 
syphilitic  differs  but  little  from  that  of  the  chancroidal 
bubo,  described  later.  "  Mixed  "  chancres  are,  of  course, 
liable  to  be  complicated  by  "  mixed  '"'  buboes, 

The  buboes  of  chancres  of  the  genital,  progenital,  and 
anal  region  in  men,  somewhat  more  rarely  in  women, 
are  found  in  the  groin  ;  chancres  of  the  lips  and  chin 
are  usually  accompanied  by  buboes  of  the  submaxillary 
glands  :  of  the  tongue,  by  changes  in  the  subhyoidean 
glands ;  of  the  inner  and  outer  canthus  of  the  eyes,  by 
involvement  of  the  pre-auricular  gland ;  of  the  fingers, 
hand,  arm,  and  shoulder,  by  bubo  of  the  epitrochlear 
and  the  axillary  glands ;  of  the  nipple  and  breast, 
by  changes  in  the  axillary  glands.  Great  multiplicity 
of  ganglionic  enlargements  is  more  common  when  the 
chancre  is  near  a  large  lymphatic  plexus.  A  chancre 
of  the  finger,  for  example,  may  be  accompanied  by 
an  epitrochlear  or  axillary  adenopathy  where  but  one 
or  two  glands  are  implicated ;  while  a  singularly  inno- 
cent-looking chancre  of  the  frenum  may  be  responsible 
for  a  dozen  ganglia  in  the  two  groins,  each  of  ivory-like 
hardness.  There  is  no  correspondence  between  multi- 
plicity of  chancres  and  multiplicity  of  buboes  in  spyhilis, 
nor  does  the  extent  or  the  gravity  of  either  the  primary 
lesion  or  its  accompanying  adenopathy  argue  unfavor- 
ably with  respect  to  the  gravity  of  the  oncoming  syphilis. 


ACQUIRED   SYPHILIS.  55 

Diagnosis  of  Syphilitic  Adenopathy. — The  determina- 
tion of  the  existence  of  a  chancre  in  any  doubtful  case 
throws  a  flood  of  light  on  the  character  of  a  suspected 
glandular  involvement  in  its  neighborhood.  Rarely, 
and  yet  occasionally,  a  bubo  can  be  recognized  where 
the  chancre  cannot  be  found  and  where  the  patient 
has  no  knowledge  of  the  previous  existence  of  such  a 
primary  lesion. 

The  bubo  of  chancroid  differs  markedly  from  that  of 
the  syphilitic  chancre  in  that  the  former  is  usually  not 
always  single,  is  inflammatory  in  character,  is  tender  and 
painful,  and  often  bursts  spontaneously  or  requires  surgi- 
cal interference  for  the  evacuation  of  the  pus  which  it 
contains.  Again,  the  bubo  of  chancroid  is  usually  in- 
guinal, while  that  of  syphilis  may  be  found  in  other 
regions  of  the  body  where  the  glands  are  situated  near 
a  site  of  syphilitic  infection.  Indolent  and  painless  en- 
largements of  glands  in  the  groins,  and  also  in  other 
regions  of  the  body,  occur  in  the  course  of  many  dis- 
orders, each  of  which  should  be  eliminated  before  estab- 
lishing a  diagnosis  of  syphilitic  adenopathy.  Among 
such  disorders  may  be  named  tuberculosis  and  scrofu- 
losis  ;  lepra ;  glanders  ;  carcinoma ;  sarcoma ;  a  series  of 
cutaneous  disorders  including  severe  eczema,  lichen 
ruber,  and  elephantiasis ;  and  a  large  number  of  trauma- 
tisms, including  cutting  and  applying  caustics  to  corns 
on  the  feet,  and  non-specific  ulcerations  of  the  skin  of 
the  legs  {e.  g.  ulcus  e  venis  varicosis).  Lastly,  it  is  to  be 
remembered  that  gonorrhoea  is  in  some  cases  accom- 
panied by  inguinal  buboes  which  are  to  a  degree  similar 
to  the  syphilitic  ganglia,  though  very  rarely  as  densely 
indurated. 

Lymphangitis  Indurata. — In  connection  with  the 
syphilitic  bubo,  or  it  may  be  without  the  development 
of  the  latter,  the  lymph-spaces  about  both  arteries  and 
veins  and  the  lymphatic  trunks  accompanying  the  latter 
may  be  characteristically  altered  by  the  toxines  received 
from   the   chancre.     The  most  common  of  these  mani- 


56         SYPHILIS  AND    THE   VENEREAL   DISEASES. 

festations  is  declared  in  the  formation  of  indurated  cords, 
like  strings  of  catgut,  felt  beneath  an  unaltered  integu- 
ment and  running  from  the  site  of  infection  toward  the 
glands.  The  most  conspicuous  picture  of  this  complica- 
tion of  the  disease  can  be  seen  upon  the  penis  in  male 
subjects,  where  one  or  more  of  these  dense  cords  may 
be  felt  coursing  toward  the  pubes  from  an  infected  glans, 
from  the  size  of  a  thick  knitting-needle  to  that  of  a 
slender  pencil,  straight  or  slightly  curved,  and  of  uni- 
form diameter,  or  rather  more  often  with  swollen  nodules 
at  irregular  intervals  along  the  cord. 

All  these  phenomena  are  characterized,  like  the  bubo 
of  syphilis,  by  extreme  indolence  of  development,  by 
non-inflammatory  changes  in  the  vessels,  and  by  special 
persistency  in  their  development  and  career.  Very  rarely 
they  also  represent  a  "  mixed  "  infection,  and  then  may 
either  traverse  the  subdermal  tissues  to  a  suppurating 
gland  or  may  themselves  exhibit  at  one  or  more  points 
in  their  course  tender,  reddened,  and  painful  points  where 
pus  is  formed  and  finds  exit  to  the  surface  through  the 
boggy  skin.  These  are,  however,  exceedingly  rare  acci- 
dents of  syphilitic  infection. 

Lymphatic  induration  usually  begins  at  the  time  of 
the  specific  induration  of  the  chancre,  and  is  relieved  at 
about  the  same  period. 

Treat?ne7it  of  Syphilitic  Bnbo  and  of  Lymphatic  Indu- 
ration.— The  buboes  accompanying  syphilitic  chancre 
often  require  no  treatment  beyond  that  advised  for  the 
initial  sore,  whether  local  or  by  internal  medication,  as 
the  progress  of  the  one  toward  a  favorable  issue,  or  the 
reverse,  is  usually  proportioned  to  the  improvement  or 
aggravation  of  the  other.  Often  the  glands  are  neither 
large,  painful,  nor  tender,  the  patient  scarcely  appre- 
ciating the  fact  of  their  undue  size  and  hardness.  In 
other  cases  they  are  voluminous  and  are  the  source 
either  of  local  distress  or  of  discomfort  experienced  in 
the  movement  of  neighboring  parts  (leg,  thigh,  arm,  jaw, 
etc.).     In  this  condition  frequent  ablution  of  the  glands 


ACQUIRED   SYPHILIS.  57 

with  water  as  hot  as  can  be  tolerated  is  the  best,  simplest, 
and  most  grateful  method  of  treatment,  followed,  when 
needed,  by  a  weak  mercurial  salve  well  rubbed  into 
the  skin  covering  the  glands — ammoniated  mercury,  10 
grains  to  the  ounce  of  lanolin  and  vaseline ;  mercurial 
ointment,  I  part  to  10  of  simple  unguent.  To  either 
salve,  when  there  is  much  pain  and  tenderness,  a  small 
quantity  of  the  extract  of  belladonna  or  of  the  watery 
extract  of  opium  may  be  added.  These  unguents  should, 
however,  be  not  too  amply  supplied  with  drugs  of  the 
narcoti co-stimulant  class,  as,  even  in  the  strength  of  10 
grains  to  the  ounce,  systemic  effects  have  been  induced 
after  application  to  the  groin. 

In  the  event  of  "  mixed  "  bubo  there  commonly  results 
abscess  of  the  glandular  contents  and  either  spontaneous 
or  artificial  opening  of  the  same.  The  treatment  of  this 
complication  is  that  of  the  bubo  of  soft  chancre. 

With  the  healing  of  the  chancre,  when  this  is  secured 
before  the  onset  of  general  symptoms,  ends  a  tolerably 
well-defined  phase  of  syphilis,  the  period  once  called 
that  of  "  primary  syphilis,"  the  period  of  lesions  for 
the  most  part  localized.  Yet  here,  even  at  the  outset  of 
the  evolution  of  the  disease,  it  is  made  clear  that  no 
sharply-defined  limits  or  periods  are  observed.  For, 
as  has  already  been  shown,  the  chancre  may  at  times 
persist  long  after  general  symptoms  have  been  declared, 
and  traces  of  it  may  be  discernible  even  when  grave 
complications  of  general  intoxication  have  occurred. 

The  Evolution  of  Syphilis  in  Stages  or  Excur- 
sions. 

In  the  early  part  of  the  present  century  Fernel  and 
Hunter  were  followed  by  the  late  eminent  Philip  Ricord 
in  establishing  for  the  evolution  of  syphilis  an  artificial 
system  based  upon  chronological  data.  This  system 
commended  itself  to  the  medical  men  of  the  scientific 
world,  and  as  a  result  it  secured  at  an  early  date  almost 
universal  acceptance.     According  to  this  scheme,  there 


58        SYPHILIS  AND    THE    VENEREAL  DISEASES. 

were  three  "  stages  "  of  the  disease  :  a  "  primary  "  stage, 
inclusive  of  the  period  of  the  infecting  chancre  and  its 
accompanying  adenopathy ;  a  "  secondary "  stage,  last- 
ing from  a  few  months  to  two  or  three  years,  in  which 
appeared  most  of  the  syphilodermata  and  the  disorders 
of  the  appendages  of  the  skin  and  the  mucous  mem- 
branes ;  and  a  "  tertiary  "  stage,  lasting  indefinitely  from 
the  close  of  the  secondary  period  until  a  final  result  was 
reached  either  in  one  direction  or  the  other,  with  the 
absolute  cessation  of  the  malady.  In  this  latter  stage 
occurred  most  of  the  affections  of  the  deeper  tissues,  of 
the  viscera,  the  bones,  the  testes,  the  nervous  centres, 
and  the  fibrous  and  subcutaneous  structures.  The 
"secondary"  was  supposed  to  follow  the  "primary," 
and  the  "  tertiary "  was  supposed  to  follow  the  "  sec- 
ondary" stage. 

The  objections  to  this  chronological  scheme  have 
been  multiplying  for  the  last  few  years,  until  it  has 
become  needful  either  to  abandon  wholly  its  ingenious 
suggestiveness  or  to  admit  it  and  its  conclusions  only 
with  exception  and  reserve.  First  among  these  objec- 
tions may  be  named  the  implication  that  a  classical 
syphilis  should  in  its  evolution  persist  throughout  these 
three  "  stages ;"  the  fact  being  that,  as  statistics  clearly 
indicate,  the  largest  number  by  far  of  all  cases  of 
syphilis  never  exhibit  any  signs  of  a  "  tertiary  "  stage. 
Second,  the  implication  was  made  that  in  any  given 
stage,  especially  in  the  so-called  "  secondary,"  the 
evolution  of  symptoms  observed  a  definite  order  like 
that  of  the  "  stages,"  one  crop,  for  example,  of  syphilo- 
dermata following  another  in  a  definite  procession  of 
symptoms ;  the  facts  being  quite  opposed  to  such  a 
course,  seeing  that  a  syphilis  thus  regularly  evolved, 
however  conformed  to  the  artificial  time  schedule  of 
the  schools,  is  clinically  never  seen.  Third,  there  was 
overlooked  or  ignored  a  series  of  facts  in  which  the 
chronological  order  of  the  scheme  was  violently  reversed, 
so-called    "  tertiary  "    symptoms    following    "  primary  " 


ACQUIRED   SYPHILIS.  59 

without  the  evolution  of  any  lesions  which  properly 
belonged  to  a  "  secondary "  stage ;  while  even  the 
symptoms  of  the  "  secondary "  period  were  at  times 
found  to  succeed  instead  of  preceding  those  described 
as  "  tertiary."  Lastly,  a  fact  of  serious  importance  in 
the  study  of  syphilis  was  to  be  considered — the  fact  that 
many,  if  not  actually  the  larger  number,  of  all  cases  of 
grave  disease  are  thus  grave  from  an  early  moment  in 
the  career  of  the  malady,  so-called  "tertiary"  symptoms 
developing  with  a  degree  of  rapidity  as  startling  as  it  is 
portentous.  It  was  in  recognition  of  these  obvious  and 
numerous  violations  of  their  chronological  system  that 
the  French  have  been  obliged  to  coin  such  explanatory 
phrases  as  "precocious,"  "late,"  "tardy,"  "galloping," 
etc. — terms  confessing  the  inadequacy  of  the  time 
schedule,  and  yet  employed  not  in  the  ordinary  course, 
but  in  the  grave  crises  of  the  malady — epochs  when  a 
fairly  good  working  system  should  be  ready  and  fitted 
for  every  emergency  that  may  arise. 

In  order  to  grasp  intelligently  the  facts  of  syphilis  as 
they  actually  occur,  it  is  well  to  make  no  attempt  to 
force  them  into  accordance  with  an  artificial  scheme, 
however  cleverly  arranged  and  readily  understood,  but 
rather  to  classify  them  in  natural  divisions.  Thus 
studied,  it  will  be  seen  that  for  the  vast  number  of  all 
cases  of  the  disease  there  is  no  fixed  line  of  demarcation 
between  its  consecutive  phenomena,  and  no  fixed  period 
of  time  in  which  any  given  series  of  symptoms  will  be 
begun  or  concluded.  From  the  moment  of  infection  to 
any  conclusion  which  the  disease  may  acknowledge 
there  is  a  regular  progression,  not  along  one  line,  but 
along  many  lines,  and  these  lines  never  alike  or  parallel, 
but  divergent  in  a  thousand  directions.  By  classifying 
in  certain  groups  these  excursions  along  various  routes 
a  systematic  knowledge  of  the  evolution  of  syphilis 
may  be  obtained.  Instead  of  a  chronological  schedule, 
one  may  more  profitably,  to  use  a  different  figure, 
employ  the  radii  of  a  circle  to  represent  to  the  mind  the 


60        SYPHILIS  AND    THE    VENEREAL   DISEASES. 

divergences  of  the  different  symptoms  of  syphilis  from 
the  fixed  pathological  centre  represented  by  the  initial 
lesion. 

The  most  of  syphilitic  histories  may  be  traced  along 
the  lines  of  advance  represented  by  the  four  divisions 
hereinafter  described.  From  the  point  of  infection  each 
of  these  lines  of  advance,  or  excursions,  represents,  it 
should  be  remembered,  not  a  narrowly-bordered  path- 
way of  symptoms,  but  a  general  direction,  with  varia- 
tions deflected  on  either  hand  to  divergences  from 
other  directions — no  single  history,  perhaps,  following 
exactly  the  same  course,  but  each  trending  near  one  or 
another  of  the  excursions  defined. 

I.  Benignant  Syphilis  with  Mild  and  Transitory 
Symptoms. — Upon  one  extreme  in  this  category  are  the 
cases  in  which  typical  initial  scleroses  with  characteristic 
accompanying  adenopathy  are  followed  by  symptoms 
which  are  either  not  at  all  appreciated  by  the  subject  of 
the  disease  or  which  barely  suffice  to  awaken  his  or 
her  attention.  A  slight  efflorescence  upon  the  abdominal 
surface,  a  few  days  of  malaise,  and  the  disease  is  at  an 
end,  irrespective  of  any  treatment  whatever.  It  is  true 
that  it  has  been  claimed  that  grave  syphilis  eventually 
follows,  but  a  sufficient  number  of  these  patients  has 
been  observed  to  substantiate  the  fact  of  a  further 
complete  immunity  from  all  signs  of  the  disease. 
Similar  facts  have  been  recognized  in  attempts  at  the 
production  of  the  infectious  granulomata  in  the  lower 
animals,  and  even  in  the  vaccination  of  heifers  for  the 
purpose  of  cultivating  vaccine  virus.  There  are  simply 
some  individuals  who  seem  to  be  protected  against  the 
incursions  of  the  disease  by  reason  of  an  individual 
idiosyncrasy. 

II.  Benignant  Syphilis  with  Relapsing  or  Per- 
sistent Superficial  Symptoms. — This  is  the  excursion 
observed,  in  all  probability,  in  the  larger  number  of  all 
cases  of  syphilis  occurring  in  the  white  races,  and 
especially    among    those    inhabiting   the    northern  por- 


ACQUIRED   SYPHILIS.  6 1 

tions  of  the  American  and  European  Continents.  In 
this  category  are  to  be  recognized  the  patients  in  whom 
typical  chancres  are  followed  by  characteristic  so-called 
"early"  manifestations  of  general  syphilis.  But  all  the 
lesions  which  result  are  superficial,  and  whether,  as  is 
often  the  case,  they  prove  relapsing  or  persistent  for 
long  periods  of  time,  involution  is  finally  reached  with- 
out the  production  of  any  permanent  relics  of  the  pro- 
cess. These  histories  are  usually  those  of  skin-symp- 
toms (papules,  scales,  etc.)  disappearing  and  reappearing 
— disappearing  on  the  intervention  of  proper  treatment, 
reappearing  after  neglect  or  discontinuance  of  the  latter, 
or  when  the  health,  for  any  intercurrent  reason,  has 
been  impaired,  but  never  throughout  producing  a  pro- 
found depression  of  the  system  nor  inducing  cachexia. 
The  disease  from  first  to  last  has  been  a  serious  annoy- 
ance rather  than  a  formidable  enemy,  and  if  the  cause 
were  not  known  and  the  results  had  not  been  dreaded, 
but  little  anxiety  would  have  been  awakened  by  its 
encroachment. 

It  is  these  cases  that  furnish  abundant  proofs  of  the 
skill  of  the  trained  physician,  and  also  of  the  tremen- 
dous energy  exerted  upon  the  health  by  its  worst 
enemies,  lack  of  proper  hygiene,  alcoholism,  senility, 
debauchery,  poverty,  and  prior  wasting  disease. 
.  The  cases  included  in  this  category  may  without 
warning,  and  often  inexplicably,  exhibit  the  symptoms 
enumerated  in  any  of  the  other  excursions  described ; 
but  it  is  true  that  the  majority  of  all  cases  under  observa- 
tion develop  along  the  line  here  suggested — that  of 
symptoms  relapsing  or  persistent  and  superficial,  and, 
however  persistent,  never  ultimately  followed  by  destruc- 
tive results.  In  other  words,  patients  of  this  large  class, 
as  a  rule,  entirely  fail  of  exhibiting  symptoms  of  the 
type  described  as  "  tertiary." 

III.  Malignant  Syphilis  with  Relapsing-  or  Persist- 
ent Profound  Symptoms. — In  this  category  are  included 
the  cases  eminently  of  transitory  type.    They  are  speedily 


62         SYPHILIS  AND    THE   VENEREAL   DISEASES. 

transferred  by  the  best  of  management  into  the  list  of 
benign  cases,  or  with  and  even  without  treatment  are 
readily  exchanged  into  the  graver  list  of  malignant 
cases  catalogued  in  the  fourth  of  the  divisions  here  con- 
sidered. 

The  malignancy  of  these  cases  is  declared  in  the 
deterioration  of  the  tone  of  the  system,  in  the  produc- 
tion of  cachexia,  and  in  some  cases  by  the  degeneration 
of  lesions  which  in  other  patients  are  resolved  without 
producing  permanent  relics  of  the  process.  Here  at 
times  develop  in  the  viscera,  nerves,  bones,  etc.  gum- 
mata  which  resolve  under  appropriate  therapy  ;  at  other 
times,  when  degeneration  occurs,  the  repair  is  either 
satisfactorily  good,  or  the  damage  resulting  is  so  slight 
as  not  to  interfere  with  the  bodily  health.  The  element 
of  gravity  is  lacking  in  each  case,  however  portentous 
at  any  one  time  may  be  the  extent  or  the  depth  of  the 
invasion.  Often  it  is  the  fewness  and  depth,  rather  than 
the  number  and  degeneration,  of  the  lesions  that  justify 
the  designation  "  malignant."  It  is  in  this  class  of 
patients,  as  in  that  just  discussed,  where  the  brilliant 
results  of  medicinal  and  hygienic  treatment  of  the  disease 
are  most  effectively  exhibited. 

IV.  Malignant  Syphilis  "with  Relapsing-  or  Pro- 
found Lesions  that  are  Ultimately  Destructive. — 
In  this  division,  represented  probably  by  from  5  to  20 
per  cent.,  at  the  most,  of  all  cases  of  syphilis,  are  cata- 
logued the  number  of  patients  exhibiting  signs  of  what 
may  justly  be  described  as  grave  syphilis.  Here  the 
disintegrating  and  ulcerating  gumma  destroys  renal, 
nervous,  hepatic,  and  osteoid  cells,  pierces  through  bone 
and  cartilage  with  appalling  rapidity,  converts  into  one 
hideous  chasm  both  the  nasal  and  the  oral  cavities, 
produces  the  paralytic,  the  imbecile,  the  repulsively 
deformed,  and  at  times  pushes  its  destructive  forces  to 
a  fatal  result.  For  the  most  part,  however,  in  acquired 
as  distinguished  from  hereditary  syphilis,  even  in  grave 
cases  a  fatal  result  is  not  so  much  to   be  anticipated  as 


ACQUIRED   SYPHILIS.  63 

is  serious  damage  of  the  sort  suggested.  Syphilis  in  its 
worst  manifestations  and  activities  often  mutilates,  para- 
lyzes, and  cripples,  but  it  rarely  kills. 

In  this  connection  it  is  worthy  of  note  that  the  fright- 
ful consequences  which  hedge  about  the  track  of  the 
disease  are  not  more  conspicuous  than  the  rapidity  with 
which  it  traverses  its  path.  Often  before  the  last  traces 
of  the  infecting  sore  have  disappeared  the  hard  palate  is 
perforated,  the  body  is  covered  with  sloughing  ulcers,  or 
the  liver  is  stuffed  with  ominous  nodules.  Here  there 
has  been  no  chronological  order,  no  possible  interval  for 
the  occurrence  of  a  "  secondary "  stage,  no  pause  in 
which  even  the  best  of  treatment  might  have  averted  the 
conclusion.  It  is  these  cases  that  have  necessitated  on 
the  part  of  the  French — who  still,  for  the  most  part, 
adhere  to  the  chronological  order  of  syphilitic  manifesta- 
tions— the  adoption  of  such  phrases  as  "  galloping," 
"precocious,"  and  "lightning."  Indeed,  of  all  cases  of 
syphilis  really  entitled  to  be  termed  "  malignant,"  it  may 
be  affirmed  that  the  majority  bear  the  impress  of  such 
malignancy  in  the  rapidity  of  progress  of  the  malady. 

It  is  in  this  division  also  that  the  great  triumphs  of 
science  may  be  achieved.  Even  in  the  worst  phases  of 
syphilis — those  chiefly  displayed  in  the  fourth  of  the 
classes  here  enumerated — repair  may  be  made  to  ensue 
when  the  destruction  has  been  gravest  and  the  systemic 
results  are  most  profound. 

Between  these  four  radii  most  of  the  excursions  of 
syphilis  may  be  discerned.  These  lines  are  not  all 
rectilinear;  many  lie  along  or  near  the  main  divisions, 
but  pursue  a  tortuous  course  from  chancre  to  complete 
relief  of  all  symptoms,  the  line  now  curving  toward 
malignancy,  now  recurving  to  the  other  side.  As  a 
rule,  the  graver  the  case  the  straighter  the  excursion  ; 
the  milder  the  symptoms  the  more  numerous  the 
deflections  toward  one  side  or  the  other,  with  no  wide 
divergence  to  either.     Rarely  the  course  of  syphilis  is 


64         SYPHILIS  AND    THE  VENEREAL   DISEASES. 

to  be  represented  by  a  line  wholly  diverted  from  the 
first  to  the  fourth  of  the  main  divisions  of  the  circle 
here  suggested. 

The  determining  influences  which  result  in  these 
divergences  are  of  the  highest  importance.  First 
among  all  may  be  named  the  character  of  the  soil  in 
which  the  germ  is  implanted.  The  very  young,  the 
very  old,  those  weakened  by  other  maladies,  by  lack  of 
food  and  of  proper  hygienic  environment,  the  victims  of 
drink,  of  debauchery,  of  poverty,  of  inherited  weakness, 
— all  suffer  early  and  often  from  the  added  burden  of 
syphilis.  Second  is  to  be  named  the  early  and  effective 
intervention  of  proper  treatment.  Cases  which  have 
been  neglected,  those  in  which  the  disease  has  long  been 
either  ignored  or  treated  inefficiently,  are  apt,  before 
others,  to  display  formidable  symptoms.  A  third  cause 
is  described  by  authors  as  the  complication  resulting 
from  the  implantation  of  the  germ  of  syphilis  upon  the 
system  contaminated  with  tuberculosis,  struma,  and 
such  cognate  disorders  as  rickets,  but  these  coinci- 
dences are  much  rarer  than  is  generally  supposed. 

Fortunately  for  the  future  of  the  human  race,  the  sub- 
jects of  acquired  syphilis  are,  as  a  rule,  between  the 
middle  of  the  second  and  the  conclusion  of  the  third 
decade  of  life — a  period  when  the  system  is  best  fitted 
to  endure  the  severe  ordeal  to  which,  in  this  affection,  it 
is  reasonably  sure  to  be  subjected.  With  the  ample 
opportunities  for  good  treatment  afforded  in  the  English- 
speaking  countries  of  the  world,  the  majority  of  all  vic- 
tims of  disease  eventually  escape  payment  of  its  severest 
penalties,  marry,  and  beget  healthy  children.  Though 
afterward  they  may  in  some  degree  be  reminded  of  their 
old  enemy,  even  as  the  victim  of  an  ancient  pneumonia 
or  a  broken  thigh  has  reason  at  times  to  recall  his  for- 
mer mishap,  they  go  to  their  graves  as  do  other  men  and 
women,  with  diseases  of  a  different  type,  and  with  con- 
sequences unchanged  by  the  infection  wrought  at  an 
early  period  of  life. 


ACQUIRED   SYPHILIS.  65 

The  Evolution  of  Syphilis  Subsequent  to  the 
Chancre. 

It  has  been  shown  that  chancres  may  persist  to  a 
point  of  time  long  after  the  exhibition  of  signs  of  gen- 
eral infection.  Often,  however,  the  period  which  may 
be  described  as  the  chancre-stage  has  been  completed 
fully  before  such  general  symptoms  appear.  The  term 
"  primary  syphilis,"  as  has  been  shown,  was  once  em- 
ployed to  designate  this  chancre-stage,  and  the  next 
period  of  evolution  of  the  disease  was,  as  distinguished 
from  that  which  preceded  and  that  which  followed, 
called  the  stage  of  "  secondary  syphilis."  Between  the 
two  periods  it  was  believed  and  taught  that  a  distinct 
interval  of  pause  or  arrest  occurred ;  this  interval  was 
given  the  title  of  "  the  second  incubation,"  as  subse- 
quent in  time  to  what  was  called  "  the  first  incubation  " 
of  the  chancre.  It  is  true  that  in  many  cases  an  appar- 
ent delay  occurs  after  a  distinct  conclusion  of  the  chancre- 
stage  before  general  symptoms  of  syphilis  are  declared, 
but  it  is  equally  certain  that  in  other  cases  there  is  no 
appreciable  delay,  and  that  in  yet  others,  where  such 
delay  or  pause  seems  to  occur,  it  is  due  to  an  apparent 
rather  than  a  real  incubation.  Its  features,  when  studied 
with  the  utmost  care  and  skill,  are  declared  both  in  the 
skin  and  elsewhere  as  symptoms  of  the  gradual  evolu- 
tion of  the  infective  disorder,  without  any  well-marked 
arrest.  The  wide  range  ascribed  to  this  period  of  sup- 
posed incubation — from  a  few  days  to  as  many  months 
— is  a  sufficient  indication  of  the  lack  of  precision 
involved  in  the  use  of  the  term.  In  general,  it  may  be 
said  that  from  the  date  of  the  appearance  of  a  chancre  to 
that  of  appreciable  general  syphilitic  symptoms  from 
forty  to  fifty  days  may  elapse.  In  rare  cases  eighty, 
ninety,  and  even  one  hundred  days  have  intervened. 
This  supposed  period  of  incubation  is  without  question 
shortened  in  malignant  and  rapidly-evolved  cases,  and  is 
lengthened  in  those  where  an  excellent  constitution  of 


66        SYPHILIS  AND    THE    VENEREAL    DISEASES. 

the  patient,  exceptionally  good  treatment,  or  the  mild- 
ness of  the  disorder  has  interposed  a  barrier  to  the  ex- 
tension of  the  malady. 

It  is  wellnigh  demonstrable,  with  the  ample  means  at 
the  disposal  of  the  expert,  that  from  the  moment  of  the 
appearance  of  the  chancre  to  the  date  of  the  onset  of  the 
earliest  symptoms  of  generalized  disease  the  signs  of  a 
gradual  intoxication  are  with  each  day  of  its  advance 
progressively  apparent.  These  symptoms,  often  at  first 
obscure,  become  usually  much  more  obvious  as  the  term 
of  the  supposed  incubation  draws  to  its  further  limit. 
Even,  however,  to  the  gross  observation  of  the  eye 
the  victim  of  infection  loses  at  the  outset  the  usual 
appearance  of  health,  and  exhibits  another  which 
gradually  acquires  characteristic  features — features  by 
which,  at  times,  the  stadium  of  the  disease  may  be 
recognized. 

The  skin,  especially  of  the  face,  which  is  most  often 
exposed  to  the  eye  of  the  observer,  assumes  a  peculiar 
sallow  or  muddy  hue  varying  from  a  yellowish  shade 
to  a  deep  reddish,  somewhat  empurpled  tint.  The  facial 
expression  may  be  one  of  dejection ;  there  is  often 
cephalalgia,  anorexia,  vague  or  very  well  marked  rheu- 
matoid pains,  headache  and  backache,  lassitude,  neur- 
algia of  various  nerve-trunks,  and,  in  cases,  typical 
jaundice.  By  due  exploration  it  may  be  discovered  that 
transitory  effusions  have  occurred  beneath  the  perios- 
teum of  exposed  bones  :  there  may  be  retinal  hyperaemia, 
hepatic  and  splenic  enlargement,  or  albuminuria.  The 
percentage  of  the  oxyhaemoglobin  decreases  with  the 
number  of  the  red  blood-corpuscles,  while  the  leucocytes 
increase.  It  is  during  this  period  also  that  there  occur 
thermal  changes  which  have  been  summed  up  rather 
loosely  under  the  term  "  syphilitic  fever." 

The  febrile  symptoms  recognized  in  an  early  or  a  late 
phase  of  syphilis  occur  neither  with  sufficient  frequency 
nor  with  sufficiently  characteristic  features  to  justify  the 
employment  of  a  distinctive  term.     These  thermal  varia- 


ACQUIRED   SYPHILIS.  6j 

tions  are  most  often  of  early  occurrence,  either  before  or 
soon  after  the  exhibition  of  constitutional  symptoms,  and 
are  in  general  due  to  the  reaction  of  the  system  against 
the  recently-introduced  and  multiplying  toxine  of  the 
malady.  Abnormal  thermal  variation  may  be  wanting  in 
more  than  50  per  cent,  of  all  cases  examined,  or  may  be 
so  slight  as  scarcely  to  attract  attention ;  or  it  may  be  in 
a  high  degree  pronounced,  the  physician,  unaware  of  the 
precise  cause  of  the  disturbance,  not  infrequently  assum- 
ing that  the  patient  is  suffering  from  a  tertian  or  quotidian 
miasmatic  fever.  In  well-marked  and  classical  cases  the 
temperature  prior  to  the  earliest  eruptive  phenomena 
rises  to  1030  and  even  to  1070  F.,  and  may  then  assume  a 
continued  or  intermittent  type  with  vespertine  exacerba- 
tion. The  fever  is  rather  more  often  observed  in  the 
cachectic  and  weak  than  in  the  strong,  and  is  often  a 
precursor,  when  well  marked,  of  a  severe  type  of  con- 
secutive symptoms.  It  is  said  to  be  more  common  in 
women  than  in  men,  but  on  this  point  there  should  be 
great  reserve.  Fevers  occurring  in  other  stages  of  the 
disease  are  usually  symptomatic  of  destructive  processes 
due  to  the  disease ;  though  it  is  to  be  noted  that  the 
subject  of  syphilis  is  often  in  a  depressed  condition,  and 
furnishes  a  large  field  for  the  invasion  of  intercurrent 
disorders,  such  as  la  grippe  and  tonsillar  and  bronchial 
affections,  several  of  which  may  excite  febrile  reactions 
not  directly  connected  with  the  specific  affection. 

Involvement  of  the  Lymphatic  Glands. 

{A)  The  Superficial  Ganglia. — The  syphilitic  bubo, 
or  specific  induration  and  enlargement  of  certain  glands 
in  anatomical  proximity  to  the  site  of  infection,  has 
already  been  described.  It  is  at  a  period  later  in  the 
evolution  of  the  disease,  and  usually  at  or  near  the 
close  of  the  so-called  period  of  "  second  incubation," 
that  the  lymphatic  system  (the  glands,  more  particu- 
larly, of  the  several  accessible  regions  of  the  body) 
exhibits  characteristic   changes.     In   well-marked  cases 


68         SYPHILIS  AXD    THE   VENEREAL   DISEASES. 

one,  if  not  quite  all,  of  the  glands  which  may  be  appre- 
ciated by  the  touch  of  the  observer  becomes  enlarged, 
engorged,  soft,  and  voluminous,  as  distinguished  from 
the  densely-indurated  buboes  accompanying  the  chancre. 
This  ganglionic  engorgement  is  one  of  the  most  constant 
of  the  signs  of  systemic  syphilis,  and  though  at  times 
it  may  escape  observation  or  actually  be  absent,  it  is 
so  conspicuous  a  feature  of  some  cases  that  patients 
themselves  often  call  attention  to  it.  At  a  given  mo- 
ment it  may  be  the  sole  appreciable  symptom.  It 
betokens,  when  well  marked,  a  general  intoxication,  and, 
though  not  always  proportioned  to  the  intensity  of  the 
disease  in  any  given  case,  it  occurs  at  times  as  the  result 
of  an  individual  predisposition  to  lymphatic  disorders. 

The  glands  most  often  exhibiting  these  changes  are 
the  post-occipital,  the  chain  extending  along  the  borders 
of  the  sterno-cleido-mastoid  muscles,  the  supraclavicular, 
the  inguinal  and  axillary,  the  epitrochlear,  the  submaxil- 
lary, the  submental,  and  the  femoral.  At  times  the 
lymphatic  trunks  leading  to  these  glands  exhibit  similar 
changes. 

The  tumefied  glands  vary  in  size  from  that  of  a  bean 
to  that  of  a  pullet's  egg ;  they  are  usually  rounded  or 
oval  in  contour,  smooth  to  the  touch,  and  painless ;  at 
times,  however,  they  are  very  tender,  and,  when  not 
overlying  bony  tissue,  movable.  They  have  no  ten- 
dency to  degenerate,  in  this  respect  exhibiting  a  very 
noticeable  difference  from  the  syphiloma,  or  gummatous 
involvement,  usually  of  a  single  gland,  occurring  early 
or  late  in  cachectic  subjects.  The  syphiloma  has  a 
uniform  tendency  to  become  at  one  point  or  another 
reddened  and  porky  to  the  touch,  and  it  soon  breaks 
down  into  a  characteristic  abscess. 

The  voluminous  and  softish  ganglia  of  early  syphilis 
are  found  on  examination  to  be  constituted  by  a  small- 
celled  infiltration  of  the  lymph-channels  and  a  succulent 
fulness  of  the  tissue  about  the  latter.  Resolution  is  by 
the  ordinary  absorptive  processes. 


ACQUIRED  SYPHILIS.  69 

(B)  The  Deep  Ganglia. — The  deep  lymphatic  glands 
undergo  special  changes  when  the  viscera  with  which 
they  are  associated  are  implicated  in  the  syphilitic  proc- 
ess. They  become  hyperplastic,  voluminous,  softened, 
and  for  the  most  part,  when  incised  and  inspected  by 
the  eye,  injected.  A  large-celled  infiltration  commingled 
with  lymph-corpuscles  and  polynuclear  cells  fills  the 
lymph-spaces  of  both  glands  and  vessels.  The  glands 
chiefly  involved  are  the  prevertebral,  the  lumbar,  the 
femoral,  the  iliac,  and  the  mesenteric. 

Syphilitic  Cachexia. 

The  anaemia  and  leucocythaemia  of  syphilis  occur  either 
as  a  direct  and  sole  result  of  systemic  intoxication  or  as 
the  indirect  result  of  the  latter  in  individuals  predisposed 
to  cachexia  in  consequence  of  an  enfeebled  state  of 
the  system  or  of  constitutional  inheritance.  This  condi- 
tion is  well  seen  in  the  infantile  forms  of  the  disease  and 
in  the  victims  of  debauchery,  drink,  poverty,  hospitalism, 
filth  environment,  and  of  other  affections  than  syphilis. 
Tuberculosis,  rickets,  and  scrofulosis  are  less  frequently 
responsible  for  this  condition  than  is  generally  believed. 
The  symptoms  of  syphilitic  cachexia  may  be  declared 
early  or  late — in  the  former  event  usually  toward  the 
close  of  the  pre-exanthematous  stage  of  the  disease  ;  in 
the  latter  case  at  any  time  when  the  system  exhibits 
signs  of  exhaustion  in  consequence  of  gummatous 
changes  in  bone,  periosteum,  nerve,  or  other  important 
tissue  of  the  body. 

The  signs  of  cachexia  are  a  peculiar  dull-tinted  pallor 
of  the  skin,  with  vague  pains,  persistent  weakness,  fiab- 
biness  of  the  tissues,  a  distinct  whiteness  of  the  con- 
junctivae, emaciation,  and  manifest  disturbances  of 
digestion,  assimilation,  and  excretion.  This  condition, 
which  may  be  produced  solely  by  the  disease  and 
which  may  be  relieved  greatly  by  a  properly-directed 
ferruginous    and    mercurial    medication,    may    without 


70         SYPHILIS  AND    THE   VENEREAL   DISEASES. 

question  be  induced  or  aggravated  by  the  injudicious 
employment  of  mercury  in  the  treatment  of  the  disease. 

Other  morbid  conditions  are  recognized  at  times  in 
the  subjects  of  syphilis  who  are  in  the  period  of  so- 
called  secondary  incubation.  Some  of  these  conditions 
are  peculiar  to  the  individual,  and  would  probably  be 
awakened  by  the  excitation  of  any  sufficient  cause ; 
some  are  more  or  less  directly  traceable  to  the  irritant 
effect  of  the  newly  acquired  toxine.  Among  these  mor- 
bid states  may  be  named  hyperaemia  and  excoriations  of 
the  fauces,  and  hysterical  symptoms  in  both  women  and 
men ;  typhoid  states  with  vertigo  and  even  hemiplegic 
symptoms ;  exaggeration  of  the  tendon  and  ocular  re- 
flexes ;  analgesic  phenomena ;  slight,  at  times  even 
severe,  rheumatoid  pains  in  muscles,  bones,  and  joints. 
There  may  be  even  severe  nocturnal  aggravation  of  the 
pain,  the  condition  simulating,  but  never  exactly  corre- 
sponding to,  the  later  neuralgic  signs  of  an  osteoperios- 
titis. The  pains  here  described  may  involve  the  chest, 
and  even  accompany  a  severe  pleurisy,  with  dry  cough, 
dyspncea,  and  slight  effusion  into  the  pleural  cavity. 
The  lower  class  of  dispensary  patients  are  especially 
liable  to  exhibit  these  symptoms  and  to  suffer  from 
them  to  a  marked  degree. 

Jaundice  is  by  no  means  rare  as  a  complication  of  this 
early  period  of  systemic  syphilis.  It  is  usually  not  per- 
sistent, and  though  well  marked  in  all  its  features  is 
especially  amenable  to  specific  treatment.  It  is  probably 
due  rather  to  functional  disturbance  than  to  structural 
changes  in  the  hepatic  system. 

The  kidneys  and  the  spleen  are  involved  in  the  second 
incubative  period  to  a  greater  degree  than  is  generally 
accepted.  The  spleen  becomes  voluminous  in  many 
cases,  and  not  infrequently  is  the  seat  of  a  dull  pain. 
This  enlargement  at  times  persists  to  the  conclusion  of 
the  course  of  the  disease,  and  may  be  productive  of  dull 
pains  in  the  left  hypochondrium.  The  kidney  also  may 
become  the  seat  of  a  mild  nephritis  in  the  early  stages, 


ACQUIRED   SYPHILIS.  J I 

as  also  of  a  severe  form  of  renal  involvement  in  the 
late  stages  of  the  disease.  In  these  cases  there  is  often 
albuminuria  and  hyaline  casts  may  be  recognized  in  the 
urine.  The  subjects  of  syphilis  are  not  rarely  veterans 
of  several  blennorrhagic  attacks,  and  the  recognition  of 
albumin,  tripper-faden,  and  even  of  blood  in  the  urine 
of  patients  who  are  enduring  the  early  stages  of  syphilis 
is  by  no  means  rare  in  our  experience.  Glycosuria  and 
peptonuria,  though  reported,  are  exceedingly  rare  com- 
plications of  the  disorder. 

Early  involvement  of  the  bones,  especially  the  parietal 
and  frontal,  the  clavicle,  and  the  sternum,  may  also 
occur  during  the  invasion  period  of  the  disease ;  and 
transitory  swellings  may  then  be  recognized,  single  or 
multiple,  scarcely  perceptible,  or  attaining  the  dimensions 
of  an  almond.  These  lesions  usually  betoken  osseous 
disease,  which  assume  the  phases  of  severe  bone- 
changes  persisting  until  the  later  periods  of  the  disease 
are  reached. 

Affections  of  the  synovial  sacs  of  the  larger  joints 
may  be  expected  with  unfailing  regularity  in  a  certain 
small  percentage  of  the  infected.  The  subjects  are 
usually  thin,  cigarette-smoking,  and  dissipated  male 
patients  with  delicate  constitutions.  The  effusion  most 
often  distends  the  knee-joint  of  one  side,  though  other 
articulations  may  be  involved.  There  are  the  usual 
signs  of  a  hydrarthrosis,  with  stiffness,  pain,  tender- 
ness, and  limitation  of  motion.  As  with  non-syphilitic 
patients,  there  is  apt  to  be  recurrence  of  the  effusion 
after  absorption  of  the  effused  synovium.  In  other 
cases  peri-articular  symptoms  are  most  marked,  and 
there  are  present  the  signs  of  acute  articular  rheumatism, 
with  several  swollen  and  painful  joints,  and  even  with 
rheumatic  fever.  Usually  the  latter  is  of  mild  grade 
and  with  no  tendency  to  produce  cardiac  compli- 
cations. 


72         SYPHILIS  AND    THE   VENEREAL   DISEASES. 


Syphilis  in  Relation  with  Coincident  Injuries  and 
Accidents. 

It  was  at  one  time  believed,  largely  on  a pj'iori  grounds 
and  after  insufficient  observation  of  cases,  that  syphilitic 
infection,  if  relatively  recent,  predisposed  its  subject 
to  the  exhibition  of  special  lesions  or  special  disturb- 
ances when  exposed  to  traumatisms  or  to  diseases  of  a 
different  origin.  These  views  have  been  changed  radi- 
cally since  the  date  of  a  wider  knowledge  on  the  subject 
of  the  antagonism  of  toxines.     • 

As  a  matter  of  fact,  the  subject  of  recent  syphilis 
exhibits  a  tendency  to  the  production  of  lesions  at  sites 
of  irritation  (condylomata  about  the  uncleansed  anus ; 
mucous  patches  of  the  mouth  irritated  by  tobacco, 
smoked  or  chewed  ;  palmar  lesions  of  the  hand-worker) ; 
but  it  is  also  tolerably  clear  that  for  the  most  part 
syphilitic  subjects  undergo  surgical  operations  (cachexia 
and  its  complications  aside)  with  very  much  the  same 
results  as  in  the  non-infected.  They  also  exhibit  the 
classical  signs  of  local  irritation,  not  different  from  those 
seen  in  others  (urticaria  from  the  attacks  of  vermin; 
erythematous  redness  on  the  application  of  a  sinapism ; 
zoster  after  exposure  of  a  nerve-trunk  to  the  predispos- 
ing causes  of  that  affection,  etc.).  It  is  now  accepted 
that  all  pus-production  in  syphilis  is  the  result  of  mixed 
infection,  and  that  the  staphylococci  multiply  in  its  sub- 
jects as  at  other  times  and  in  other  persons. 

On  the  supervention  of  other  typical  disorders  in 
those  under  the  influence  of  syphilis,  the  result  is  con- 
ditioned upon  the  proportionate  activity  of  the  one  or  the 
other  malady.  Recently-infected  syphilitic  subjects  ex- 
posed to  typhoid  fever  speedily  lose  all  symptoms  of  the 
original  and  exhibit  all  classical  features  of  the  later  dis- 
ease, even  to  the  date  of  a  slow  and  apparently  typical 
convalescence.  On  the  re-establishment  of  the  health  the 
syphilitic  affection,  after  an  apparently  absolute  quies- 
cence  for  weeks,   resumes  its  former  activity,  and  the 


SYPHILIS   OF  THE   SKIN.  73 

progress  of  the  infective  process  seems  to  be  resumed  at 
the  point  where  it  was  temporarily  interrupted. 

Considering  the  number  of  both  tuberculous  and 
syphilitic  subjects  in  large  cities,  it  is  a  matter  of 
great  surprise  that  experts  are  so  seldom  confronted 
with  the  coincidence  of  the  two  affections  in  one  indi- 
vidual ;  the  same  may  be  said  of  syphilis  and  of  carci- 
noma, though  the  different  ages  of  the  patients  liable 
to  display  early  symptoms  of  these  two  affections  may 
here  exert  some  influence  upon  the  statistics.  An 
attack  of  erysipelas  has  often  cleared  the  skin  of  syphi- 
litic lesions,  and,  even  when  occurring  in  a  patient  whose 
luetic  affection  was  grave,  has  emphasized  the  date  of  a 
recovery  without  further  relapse.  Indeed,  of  the  larger 
number  of  all  injuries  and  diseases  occurring  as  acci- 
dents of  the  period  when  the  subject  of  syphilis  is  dis- 
playing evidences  of  his  disease,  it  may  safely  be 
asserted  that  they  proceed  to  a  conclusion  which  would 
have  been  anticipated  if  no  systemic  infection  had 
existed. 

Syphilis  of  the  Skin. 

In  hereditary  syphilis  the  bones  or  the  viscera  may 
first  manifest  the  signs  of  the  affection,  since  the  new 
being  is  vitiated  ab  ovo.  In  acquired  syphilis,  on  the 
contrary,  the  most  obvious  of  the  early  lesions  of  the 
disease  are  perceptible  in  the  skin  and  its  underlying 
connective  tissue  and  upon  the  mucous  surfaces  as  well 
as  in  the  superficial  lymphatic  glands  and  vessels. 

"  Syphiloderma  "  is  a  term  used  to  include  many  of 
these  superficial  lesions,  the  early  eruptive  and  late  infil- 
trations and  deposits  being  termed  "  syphilodermata," 
or,  as  the  term  has  been  anglicized  since  its  first 
employment  by  the  French,  syphilides.  The  word 
"  syphiloma  "  is  generally  restricted  to  (late)  gummatous 
deposits  in  the  several  organs  of  the  body,  not  merely 
in  the  skin,  but  also  in  the  bones  and  the  viscera. 

The  study  of  the  eruptive  symptoms  in  syphilis  is  of 


74        SYPHILIS  AND    THE  VENEREAL   DISEASES. 

the  very  greatest  importance  not  only  for  the  expert, 
but  also  for  him  who  aims  to  be  an  accurate  diagnos- 
tician in  any  department  of  medicine.  He  who  cannot 
properly  interpret  these  significant  symptoms  is  usually 
not  merely  an  ignorant  but  an  unsafe  practitioner.  The 
peace  of  families,  the  conservation  of  the  marriage 
relation  between  husband  and  wife,  the  reputation  of  an 
innocent  girl,  and  the  health  of  uninfected  men,  women, 
and  children  may  all  be  hazarded  by  the  decision  of  a 
single  case. 

General  Features  and  Relations  of  the  Syphiloder- 
mata. — Syphilis  may  invade  every  organ  of  the  body  ; 
it  may  also  involve  any  portion  of  the  skin.  As  the 
chancre  may  be  situated  on  any  part,  so  the  syphilo- 
derm  may  develop  upon  any  given  point  of  the  bodily 
surface.  As  it  has  been  seen  that  the  chancre  may  be 
represented  by  every  one  of  the  several  elementary  and 
consecutive  lesions  of  the  skin,  so  the  syphilodermata 
may  develop  in  each  of  several  forms — as  a  macule,  a 
papule,  a  tubercle,  a  pustule,  a  bleb,  or  a  tumor — and 
may  betray  such  consecutive  lesions  as  scales,  crusts, 
ulcers,  rhagades,  fissures,  and  scars.  A  study  of  the 
syphilodermata  is,  in  fact,  a  study  of  the  changes 
impressed  by  the  infective  process  upon  the  simple 
manifestations  of  all  skin  diseases.  A  syphiloderm  may 
resemble  an  acne,  a  psoriasis,  a  seborrhcea,  and  even  the 
skin-picture  in  variola.  To  determine  with  certainty  that 
an  eruption  is  syphilitic  it  is  essential  that  the  several 
modifications  of  lesions  produced  by  syphilis  of  the  skin 
be  recognized  fully.  The  actual  result  in  any  case  is  a 
composite  of  the  ordinary  pathological  processes  of 
congestion,  inflammation,  infarction"  of  vessel,  cell- 
multiplication,  and  secretory  changes  awakened  in  the 
tissues,  which  in  all  diseases  resent  these  processes. 

Characteristics  of  the  Syphilodermata. — Symmetry. 
— Many  disorders  of  the  skin  attended  with  eruptions 
exhibit  symmetrically-arranged  lesions,  such  as  variola, 
the  medicamentous   rashes,  and  purpura.       In   syphilis 


SYPHILIS   OF  THE   SKIN.  J$ 

the  earlier  cutaneous  symptoms  are  usually  symmet- 
rical, but  as  the  disease  progresses  the  skin-lesions 
exhibit  a  greater  tendency  to  asymmetry,  until  the 
latter  becomes  the  rule  rather  than  the  exception.  The 
macular  syphiloderm  of  an  early  stage  of  syphilis 
usually  displays  this  symmetrical  arrangement  in  a 
marked  degree. 

Color. — Too  much  significance  has  been  attributed  to 
the  supposed  characteristic  color  of  the  syphilodermata, 
though  often  the  hue  displayed  by  such  lesions  is  like 
none  other.  It  is  important  to  bear  in  mind  the  obvious 
fact  that  the  color  of  an  eruption  in  a  blonde  and  in  a 
brunette  subject,  in  an  infant  and  in  an  aged  person,  in  a 
region  such  as  the  face  and  in  another  such  as  the  inner 
and  superior  aspect  of  the  thigh,  exhibits  the  widest 
contrasts.  It  is  also  true  that  in  every  person  affected 
with  a  cutaneous  efflorescence  the  color  varies  from 
hour  to  hour  with  the  degree  of  congestion  of  the 
integument. 

In  syphilis  there  is  displayed  no  color  which  may  not 
at  times  be  recognized  in  non-syphilitic  subjects ;  but 
the  color  with  the  other  picture  presented  is  usually 
highly  suggestive.  Its  shades  vary  from  a  mixture  of 
red,  yellow,  and  brown  to  an  empurpled  hue,  and  they 
are  rarely,  if  ever,  commingled  with  the  vivid  and  frank 
rosy  tints  of  an  erythema  simplex  occurring,  for 
example,  in  a  clear-skinned  child,  or  the  pure  silver- 
white  of  the  scales  seen  in  lichen  planus.  The  terms 
"  copper-colored "  and  "  raw-ham  tint "  have  been 
employed  to  designate  the  special  hues  of  the  syphilitic 
exanthem.  The  deepest  shades  of  greenish-yellow, 
chocolate,  and  even  black  are  often  noted  as  sequences 
of  the  profound  alterations  occurring  as  the  result  of 
gummatous  ulcers,  particularly  in  the  lower  extremities. 

Polymorphism  (Multiformity). — The  frequency  of 
the  coexistence  of  several  lesions  of  different  types  in 
one  person  and  at  one  time  is  a  characteristic  of  syphilis 
shared  by  but  few  other  maladies.     It  is  not  rare  to  find 


j6        SYPHILIS  AND    THE  VENEREAL   DISEASES. 

a  subject  of  the  affection  first  named  exhibiting  at  a 
given  moment  condylomata  about  the  anus,  scaling 
patches  in  the  palms,  pustules  upon  the  face,  and 
papules  of  the  thighs.  The  chronic  career,'  frequent 
relapses,  and  ready  modification  of  syphilitic  lesions 
furnish  every  opportunity  for  variation  in  type  of  the 
syndromata  of  syphilis. 

Configuration. — The  arrangement  of  the  syphiloder- 
mata  in  groups  or,  after  coalescence,  in  figures  having 
the  outline  of  a  circle,  either  complete  or  in  segments, 
is  highly  distinctive.  Thus  are  formed  odd-looking  and 
characteristic  groups  of  lesions  in  figures  suggesting  the 
shape  of  a  horse-shoe,  a  kidney,  the  letter  S,  the  figure 
8,  and  the  arrangement  of  a  brooch  in  oval  or  circular 
pattern  with  crescentic  or  circular  "  satellites "  at  its 
outer  rim.  The  "  serpiginous  "  feature  of  certain  of  the 
syphilodermata  is  the  result  of  an  evolution  of  lesions  in 
similar  lines  spreading  from  one  point  of  the  skin  to 
another  in  crescentic  curves.  This  special  configuration 
is  probably  associated  with  the  distribution  of  the 
cutaneous  nerves  in  definite  areas. 

Absence  of  Subjective  Sensations. — The  absence  of 
itching  and  pain  in  the  great  majority  of  syphilitic 
subjects  displaying  eruptive  symptoms  is  a  striking 
feature  of  the  disease.  The  exceptions  are,  however, 
often  well  marked,  a  peculiarly  sensitive  individual 
suffering  from  pruritus  even  with  macular  lesions.  It  is 
also  to  be  remembered  that  in  a  few  special  syphilitic 
lesions  (particularly  condylomata  about  the  anus  and 
the  vulva,  pustules  upon  the  scalp,  etc.)  the  itching  may 
be  extraordinarily  severe,  while  the  pain  of  a  syphilitic 
ulcer  may  be  excessive.  It  is  none  the  less  remarkable 
with  how  much  toleration  the  average  patient  displays  an 
abundant  exanthem  covering  almost  the  entire  surface  of 
the  body.  Indeed,  a  careful  physician  is  often  the  first 
to  detect  a  syphilitic  rash,  the  patient  being  wholly  un- 
conscious of  its  existence  until  informed  of  the  fact. 

Mode    of   Evolution. — The    syphilodermata    are    de- 


SYPHILIS    OF   THE   SKIN.  J  J 

veloped  with  remarkable  indolence,  and  in  some  cases, 
especially  in  those  neglected,  they  have  a  tendency  to 
recur  in  different  types,  to  be  succeeded  by  others  of  a 
different  character,  and  to  undergo  extreme  metamor- 
phoses in  situ,  so  that,  for  example,  a  papule  may 
enlarge,  flatten,  ulcerate,  or  disappear  and  be  succeeded 
by  others  pursuing  the  same  or  another  course.  It  may 
well  be  doubted,  however,  whether  this  is  so  much  a 
mode  of  evolution  of  syphilis  as  a  variation  of  its  evolu- 
tion due  to  the  accidents  of  environment.  Syphilis  is  a 
disease  of  relatively  chronic  type,  and  it  is  peculiarly 
subject  to  changes  induced  by  improvement  in  the 
general  health  of  the  patient  or  the  reverse,  and  in  favor- 
able cases  by  treatment. 

Situation. — Every  portion  of  the  bodily  surface  may 
be  the  seat  of  a  syphiloderm,  but  in  different  localities 
there  is  usually  seen  a  different  expression  of  these  local 
manifestations.  Those  of  pustular  type  are  often  seen 
upon  the  scalp  and  on  the  face ;  papules  often  appear 
over  the  neck  and  the  brow ;  secreting  lesions,  about  the 
mucous  outlets  of  the  body ;  scaling  patches,  on  the 
palms  of  the  hands,  etc. 

Peculiarities  of  Elementary  and  Consecutive  Lesions. — 
Papules  are  ever  predominant  lesions  of  an  average 
syphilitic  history.  They  are  usually  characteristically 
ham-colored,  and  in  exposed  situations  they  have  a 
tendency  to  scale  at  the  apex,  to  provide  themselves 
around  the  border  with  a  collarette  of  dirty-tinted  scales, 
and  in  others  to  flatten  into  broad  plaques,  to  crust,  and 
even  to  ulcerate. 

Tubercles  are  also  common  in  syphilis,  and  they  are 
usually  grouped.  Their  color  and  their  frequent  tend- 
ency to  ulcerate  and  crust  distinguish  them  from  the 
much  more  indolent  tubercles  of  lupus  and  lepra. 

The  crusts  of  syphilis  are  usually  bulky;  they  vary  in 
color  from  a  dirty  greenish-brown  to  a  dead  black. 
When  of  rupioid  type  they  are  made  up  of  laminated 
concretions  like  the  shell  of  the  oyster,  this  feature  being 


78         SYPHILIS  AND    THE   VENEREAL   DISEASES. 

produced  by  the  concretion  of  pus  and  other  inflam- 
matory products  upon  a  secreting  ulcer,  which,  as  it 
spreads  beneath,  furnishes  continually  a  broader  base 
for  the  conical  crust  with  which  it  is  capped. 

Scales  in  syphilitic  subjects  are  usually  thin,  are 
rarely  very  profuse  or  adherent,  and  are  of  a  dirty- 
whitish  hue.  They  never  exhibit  the  nacreous  shade 
of  the  psoriasic  skin,  nor,  as  heretofore  shown,  the 
silvery  sheen  of  the  scales  in  lichen  planus.  As  dis- 
tinguished from  similar  conditions  in  non-syphilitic  dis- 
ease, they  are  rarely  the  sole  lesions  present,  but  are 
more  often  complications  or  appendages  of  other  lesions, 
as,  for  example,  when  they  crown  the  apex  of  syphilitic 
papules  or  surround  their  base,  or,  as  in  the  palm  or  the 
sole,  when  they  furnish  a  ragged  fringe  encircling  a  dull- 
red  patch  either  ulcerating  or  threatening  such  destruc- 
tive action. 

Ulcers  in  syphilis  are  usually  characteristic.  Their 
base  is,  as  a  rule,  soft ;  their  edges  are  steep  or  under- 
mined and  have  a  punched-out  appearance ;  their  floor 
is  covered  with  a  foul  pultaceous  slough ;  their  secre- 
tion is  purulent  or  haemorrhagic ;  and  their  crusts  are 
of  the  character  described  above.  Often  they  are  sur- 
sounded  by  an  angry  halo.  Their  outline  commonly 
observes  the  several  circular  shapes  already  suggested, 
such  as  the  arc  of  a  circle,  a  horseshoe,  a  semilunar 
figure,  etc. 

Scars  left  as  relics  of  ulcerative  and  degenerative  lesions 
are  in  syphilis  usually  pigmented  when  recent,  but  when 
old  the  pigment  gradually  disappears  from  centre  to  cir- 
cumference. In  circular  or  oval  contour  they  conform, 
for  the  most  part,  to  the  configuration  of  the  ulcer  or 
group  of  lesions  that  preceded  their  formation.  When 
completely  freed  from  their  chocolate-tinted  or  violace- 
ous pigmentation  they  are  of  a  dead-white  shade,  not 
greatly  differing  in  this  respect  from  scars  in  general, 
but  they  are,  as  a  rule,  much  smoother,  more  superficial, 
less  attached,  and   more  elegant   in  delicacy  of  surface 


SYPHILIS   OF  THE   SKIN.  79 

wrinkling  than  most  other  cicatrices.  Their  site  is  often 
of  striking  importance  :  as  in  syphilis,  they  are  apt  to  be 
situated  on  the  anterior  face  of  the  lower  extremities  (the 
leg  particularly),  though  they  may  form  in  any  portion 
of  the  body  (face,  arms,  scalp,  wrists,  etc.). 

General  Considerations  relative  to  the  Evolution, 
Involution,  Variation  in  Type,  and  Accidental  Feat- 
ures of  the  Syphilodermata. — The  conception  long 
held  of  the  classical  evolution  of  a  syphilitic  affection 
has  to  a  great  degree  been  modified  by  later  observation 
and  study.  With  reference  to  the  syphilodermata,  it 
was  believed,  and  with  some  reason,  that  their  evolution 
was  by  a  series  of  successive  eruptions,  the  one  in  due 
course  following  the  other,  those  of  a  so-called  "second- 
ary "  stage  at  first  symmetrical  and  superficial,  fading 
spontaneously  and  succeeded  later  by  eruptions  involv- 
ing a  deeper  structure  of  the  skin.  Thus  papules  were 
thought  to  follow  macules,  pustules  taking  the  place 
of  papules,  until  a  late  or  so-called  "  tertiary  "  stage  was 
in  proper  course  reached,  when  the  syphilodermata,  no 
longer  multiple  and  superficial,  became  fewer,  deeper, 
isolated,  and  in  various  degrees  destructive  to  the  under- 
lying tissues. 

Such  was  the  classical  ideal ;  but,  as  has  been  in  part 
already  shown,  it  was  rather  an  artificial  manikin  for  use 
in  the  schools  than  a  pattern  fashioned  after  observation 
of  cases.  If  any  such  attack  of  syphilis  has  actually  been 
observed,  it  was  certainly  an  illustration  of  the  very  rare 
exception  rather  than  of  the  rule. 

There  are  many  facts  which  lead  to  the  conviction 
that  an  attack  of  syphilis  in  a  sound  young  subject 
whose  case  is  perfectly  managed  throughout,  with  no 
intercurrent  accidents  to  change  its  features,  is  a  syphilis 
exhibiting  a  single  exanthem.  This  eruption  would  be 
of  the  type  of  the  superficial  and  symmetrical  macular 
syphiloderm,  after  the  disappearance  of  which  as  a  result 
of  vigorous  treatment  no  other  skin-lesions  would  appear. 
Persistent,  faithful,  and  skilful  management  of  the  case 


80         SYPHILIS  AND    THE   VENEREAL   DISEASES. 

subsequently  should  permit  no  further  manifestations  of 
the  malady.  This  is,  it  must  be  admitted,  a  rare  event, 
yet  it  is  one  that  can  be  studied  as  an  objective  fact,  and, 
rare  though  it  be,  it  certainly  is  not  so  rare  as  the  ideal 
case  exhibiting  in  turn  and  in  due  course  each  of  the 
syphilodermata  in  an  ordered  succession. 

The  practical  deductions  from  an  acceptance  of  this 
new  ideal  are  of  importance.  In  the  light  of  our  present 
knowledge  on  the  subject  of  micro-organisms  and  their 
role  in  the  production  of  disease,  it  is  clear  that  some  of 
the  syphilodermata  are  the  result  of  mixed  infection. 
Staphylococci  are  responsible  for  many,  if  not  all,  of  the 
pustular  lesions  in  syphilis.  Again,  it  is  capable  of 
demonstration  that  many  of  the  other  syphilodermata 
are  the  fruit  of  local  irritations,  of  errors  in  diet,  in  dress, 
in  exposure,  and  in  the  habits  of  the  patient.  The 
impression  that  every  eruption  recognized  in  the  subject 
of  syphilis  is  due  solely  to  that  disease  is  so  grossly 
misleading  that  it  should  carefully  be  excluded  from  all 
conceptions  of  the  malady.  The  medicaments  swal- 
lowed, the  soaps  employed,  the  articles  of  diet  and  drink 
consumed,  play  a  significant  part  in  many  of  the  processes 
to  be  considered  later. 

Again,  it  has  been  believed  that  the  profuseness  of  a 
syphilitic  eruption  of  early  development  bears  some 
relation  to  the  severity  of  the  disease  and  to  the  ques- 
tions concerned  in  its  prognosis.  This  is  a  conception 
based  upon  the  old  rather  than  upon  the  new  ideal  out- 
lined above.  As  a  matter  of  fact,  the  first  frank  expres- 
sion of  constitutional  syphilis  may  be  an  abundant 
exanthem  of  macular  type,  extensively  spread  over  the 
bodily  surface,  possibly  sparing  no  area,  and  this  may 
prove  of  better  augury  than  one  which  feebly  manifests 
itself  and  is  too  speedily  followed  by  the  symptoms  of 
malignancy  to  be  described  later.  Complete  involution 
of  an  eruption  of  this  character  is  often  not  followed 
by  the  evolution  of  a  crop  of  small-  or  large-papular 
syphilodermata,  nor,  indeed,  by  any  other  eruption. 


SYPHILIS    OF   THE   SKIN.  8 1 

Classification  of  the  Syphilodermata. — The  skin- 
lesions  of  syphilis  are  classified  as  follows  : 

I.   Macular.  (a)  Pigmentary. 

(b)  Erythematous. 

(c)  Purpuric. 
II.  Papular,  dry.       (a)  Miliary. 

(b)  Lenticular. 
Papular,  moist,  (a)  Mucous  patches. 
(&)  Condylomata. 

III.  Pustular.  (a)  Miliary. 

(d)  Lenticular. 

IV.  Tubercular. 
V.  Gummatous. 

The  compound  adjectives  "  pustulo  -  crustaceous," 
"  papulo-pustular,"  "  gummato-ulcerative,"  and  others 
are  employed  to  express  the  frequent  combinations  of 
elementary  and  consecutive  lesions  to  be  recognized 
clinically  in  many  cases  of  syphilis. 

In  these  pages  all  such  terms  as  "  syphilitic  psoriasis," 
"  syphilitic  lupus,"  etc.  are  discarded.  Combinations  of 
syphilis  with  other  diseases,  however  rare,  are  certainly 
never  expressed  in  dermatological  lesions,  for  an  eczema 
(which  certainly  may  occur  in  a  syphilitic  subject)  is  not 
a  "  syphilitic  eczema,"  but  is  an  eczema  of  unmodified 
type ;  and  a  scaling  syphiloderm  is  never  by  any  possi- 
bility a  "syphilitic  psoriasis,"  but  is  a  squamous  skin- 
lesion  of  the  specific  disorder  present. 

I.  Macular  Syphilodermata. 
Pigmentary. — The  pigmentary  syphiloderm  occurs 
without  previous  involvement  of  the  skin,  as  a  distinct 
network  of  pigmented,  brownish,  chocolate,  or  even 
blackish  maculae,  the  hyper-pigmentation  being  con- 
spicuous by  reason  of  contrast  with  the  white  and 
unaltered  skin  about  each  discolored  spot ;  as  a  more  or 
less  diffuse  pigmentation  of  the  skin,  with  small  areas  of 
achromia  interspersed  over  the    darker    tinted    surface; 


82         SYPHILIS  AND    THE  VENEREAL   DISEASES. 

and  lastly  as  a  mere  irregularity  of  pigment  distribution, 
the  so-called  "  marmoraceous"  form,  in  which  the  color- 
ing-matter of  the  skin  seems  to  have  been  swept  away 
from  certain  small,  well-defined  areas,  only  to  be  heaped 
up  in  excess  over  those  immediately  adjacent.  Gradu- 
ally, and  very  slowly  as  a  rule,  the  pigment  is  diminished 
in  the  centre  of  each  deposit,  and  there  is  formed  a  whitish 
central  punctum  from  which  the  pigment  is  at  last 
wholly  removed.  These  colorations  occur  as  uniform 
ill-defined  shadings,  as  pea-  to  coin-sized  spots,  or  as  a 
reticular  arrangement,  one  form  often  slowly  passing 
into  another  as  the  pigment  atrophy  and  hypertrophy 
progress  side  by  side.  The  eruption  is  seen  rather  more 
often  in  women,  and  in  them  chiefly  on  the  neck  and 
shoulders,  but  it  occurs  also  in  men,  and  over  the  face, 
neck,  and  forearms. 

This  condition  is  decidedly  more  often  seen  in 
brunettes  than  in  blondes,  in  this  particular  sharing  the 
lot  of  most  of  the  achromias  of  the  skin.  It  especially 
affects  in  both  sexes  the  Chinese,  Indians,  and  negroes 
who  have  contracted  the  disease.  It  was  once  supposed 
to  be  rare,  but  without  question  is  more  common  than 
was   believed. 

The  eruption,  if  such  it  may  be  called,  develops 
at  any  time  after  general  syphilis  is  declared,  but 
it  is  much  more  common  in  the  earlier  months  of 
the  malady.  It  is  exceedingly  indolent,  persisting 
for  months,  and  even  in  exceptional  cases  for  years, 
being  in  but  a  slight  degree  amenable  to  specific  treat- 
ment. Though  thus  persisting,  the  complete  involution 
of  the  affection  occurs  without  ulterior  changes  in  the 
skin,  which,  as  a  result,  does  not  become  the  seat  of 
infiltration,  of  degeneration,  nor  of  scaling.  Indeed,  it  is 
probably  more  an  indirect  than  a  direct  result  of  infec- 
tion, and  is  peculiar  in  that  it  is  decidedly  more  com- 
mon not  merely  in  those  predisposed  by  individual 
characteristics  to  pigment  anomalies,  but  also  in  the 
uncleanly  and  the  neglected.     Anatomically,  it  is  found 


Plate  3. 


Pigmentary  syphiloderm  of  the  neck  and  shoulders  (Mracek). 


LilfuAnsi  F.  Reichkold  Miindu 


SYPHILIS    OF   THE   SKIN.  83 

that  a  chronic  endothelial  inflammation  of  the  smaller 
cutaneous  capillaries  occurs,  under  the  influence  of  which 
the  red  corpuscles  gradually  lose  their  coloring  matters, 
while  eventually  an  obliterating  endarteritis  chokes  the 
vascular  channels.  In  the  portions  where  the  pigment 
has  apparently  been  removed  the  normal  quantity  of 
coloring  matter  has  at  times  been  recognized ;  in  other 
cases  a  true  vitiliginous  atrophy  of  the  pigment  has  fol- 
lowed. It  is  highly  probable  that  all  these  changes  are 
under  the  immediate  influence  of  the  trophic  nerves. 

The  pigmentary  syphilide  should  not  be  confounded 
with  tinea  versicolor,  which  develops  often  on  the  neck 
and  the  breast,  for  in  the  disease  last  named  not  only  is 
a  fungus  visible  under  the  microscope,  but  the  fawn- 
colored  patches  are  usually  the  seat  of  a  fine  furfura- 
ceous  desquamation,  readily  recognized  when  the  finger- 
nail is  employed  as  a  curette  over  the  surface.  The 
several  chloasmata  of  other  sources  are,  however,  to  be 
differentiated  with  care.  Many  of  them  appear  on  the 
face,  and  not  elsewhere  (the  reverse  of  what  is  usual  in 
the  pigmentary  syphiloderm).  Vitiligo  or  leucoderma 
occurs  often  on  the  scalp  as  well  as  over  the  body  and 
the  face.  Its  disks  are  far  more  extensive  than  those  of 
the  syphiloderm,  being  often  palm-sized  and  larger,  and 
when  occurring  upon  the  scalp  the  hairs  which  spring 
from  the  achromatous  patch  are  commonly  white.  In 
any  doubtful  case  the  symptoms  of  syphilis,  usually 
declared  by  other  signs  in  the  event  of  a  syphiloderm, 
should  decide  the  diagnosis. 

Circumscribed  pigmentations  of  the  skin  in  syphilis, 
and  even  of  syphilitic  lesions  themselves,  differ  in  a 
marked  degree  from  the  pigmentary  syphiloderm,  since 
all  the  former  are,  without  exception,  sequences  of  some 
other  disturbance  (relics  of  a  papular  or  tubercular 
syphiloderm,  ulceration  and  cicatrization  of  gummata, 
especially  in  the  lower  extremities,  etc.). 

The  Erythematous  Syphiloderm  ("  Syphilitic  rose- 
ola,"   "  Syphilitic    erythema ").  — It    has    already    been 


84        SYPHILIS  AND    THE    VENEREAL   DISEASES. 

shown  that  there  are  grounds  for  believing  that  syphilis 
in  an  ideal  case,  occurring  in  a  strong  and  healthy 
young  subject,  well  managed  throughout  the  entire 
career  of  the  disease,  would  probably  have  but  one 
cutaneous  expression.  That  expression  would  be  the 
erythematous  syphiloderm.  If  syphilis  be  in  type  a 
disease  of  but  a  single  efflorescence,  the  eruption  here 
designated  represents  that  exanthem.  It  is  the  most 
common,  the  most  frequent,  the  most  benign,  the  earliest, 
and  the  most  classical  of  the  skin-symptoms  of  the  disease, 
to  be  expected  in  the  great  majority  of  all  patients,  and 
rarely  failing  to  appear  when  awaited  and  searched  for  by 
the  eye  of  the  trained  physician.  It  is  also  in  syphilis  the 
exanthem  most  often  overlooked,  as  it  may  be  limited  to 
regions  covered  by  the  clothing,  and  is  for  the  most  part 
unaccompanied  by  any  subjective  sensation  such  as  itch- 
ing. Women,  especially  those  who  are  fleshy,  when 
viewing  its  blush  often  suppose  themselves  to  have  been 
simply  "overheated,"  and  men,  especially  those  inured  to 
work  in  heavy  flannels,  look  upon  its  lesions  with  no 
anxiety.  It  it  often  first  demonstrated  by  the  physician 
engaged  in  examining  a  patient  for  the  detection  of  the 
character  of  a  chancre. 

The  exanthem  usually  first  appears  between  the 
sixth  and  the  seventh  week  after  the  appearance  of 
the  chancre,  and  with  exceedingly  insidious  onset,  so 
that  on  the  very  first  inspection  only  a  few  delicately- 
tinted  spots  occur  on  the  surface  of  the  belly ;  and  in 
some  cases,  especially  after  indulging  in  a  Turkish  bath, 
a  dance,  or  a  generous  dinner  with  wine,  its  lesions  may 
be  evolved  with  surprising  rapidity. 

The  faintest  expression  of  this  syphiloderm  can  scarcely 
be  described.  It  resembles  to  a  degree  the  delicate  mar- 
bling produced  when  the  skin  of  a  healthy  person  is  ex- 
posed to  cool  air  after  immersion  in  a  hot  bath.  When 
well  defined,  the  spots  appear  as  multiple,  oval-shaped 
or  rounded,  irregularly-defined  macules,  neither  elevated 
above  nor  depressed  below  the  general  level  of  the  integu- 


SYPHILIS   OF   THE    SKIN.  85 

ment,  having  a  diameter  of  from  one-tenth  to  one- fourth 
of  an  inch.  Their  color  varies  in  different  skins  and  at 
different  stages  of  evolution  of  the  exanthem,  being 
rarely  of  a  pure  rose  or  a  vivid  pink,  but  rather  of  a  dull 
shade  of  yellowish-red,  sometimes  having  an  empurpled 
tint,  at  times  so  light  as  almost  to  suggest  a  simple 
erythema.  The  color  fades  under  pressure  of  the  finger, 
but  later  persists,  and  when  further  development  of  the 
exanthem  occurs  the  maculations  furnish  a  slight  eleva- 
tion of  the  surface  at  each  point  of  hyperaemia — a  condi- 
tion approximating  that  in  which  papular  lesions  appear. 
On  complete  involution,  which  often  occurs  without  the 
sequel  of  another  exanthem  of  the  disease,  there  may 
be  left  transitory  discolorations  or  lightly-pigmented 
macules  persisting  for  several  weeks.  As  a  rule,  under 
appropriate  treatment  the  eruption  fades,  without  the 
production  of  desquamation  or  other  consecutive  lesions, 
in  the  course  of  from  a  week  to  ten  days,  though  occa- 
sionally it  persists  for  several  weeks. 

The  abdominal  surface  and  the  chest,  both  anterior 
and  posterior,  generally  display  the  exanthem  in  great- 
est profusion,  but  it  is  also  encountered  in  vivid  efflores- 
cence over  the  extremities,  the  face,  the  neck,  and, 
indeed,  over  all  the  bodily  surface.  When  distinctly 
evolved  over  the  anterior  surface  of  the  belly  and  the 
back,  it  is  often  supposed  by  inexperienced  observers  to 
be  strictly  limited  to  these  regions,  but  in  almost  all 
cases  a  careful  search  will  •  reveal  a  faint  mottling  about 
the  outer  angles  of  the  lips,  in  the  palms  of  the  hands, 
over  the  brows,  and  elsewhere.  It  is  most  brilliantly 
displayed  on  the  abdominal  surface  when  faintly  seen 
elsewhere,  chiefly  because  of  the  warmth  and  clothing 
of  that  portion  of  the  body.  In  some  cases  it  will  be 
seen  on  close  inspection  that  the  arrangement  of  the 
macules  is  in  generally  circular  outlines. 

The  eruption  which  represents  the  transition  between 
that  just  described  and  the  papular  syphiloderm  is 
termed    the    "  maculo-papular."       Its    peculiarities    are 


86        SYPHILIS  AND    THE    VENEREAL   DISEASES. 

briefly  those,  in  varying  proportions,  of  the  two  primary 
lesions  from  which  it  has  its  name.  The  variations 
between  these  eruptive  forms,  macules  and  papules,  are 
numerous  and  interesting. 

In  an  exceedingly  common  variety  the  macular  rash 
exhibits  here  and  there,  often  with  wide  intervals  of 
space,  a  few  isolated  papules,  usually  of  the  larger  or 
lenticular  type,  scattered  with  seeming  irregularity  over 
the  eruptive  field,  and  springing  usually  from  maculae. 
They  have  a  dull-reddish  tint,  and  they  often  scale 
slightly  over  the  flattish  summit  or  at  the  base.  These 
may  be  sparsely  distributed  over  one  region  of  the 
body ;  or  when  the  trunk,  for  example,  exhibits  macules 
in  wellnigh  pure  type,  the  lower  extremities,  where 
there  has  been  some  friction  and  usually  also  effects 
of  gravitation,  display  these  papules  seated  on  an  ery- 
thematous base.  In  yet  other  cases  the  papules  are  of 
miliary  type  and  spring  in  large  numbers  directly  from 
the  erythematous  spots,  till  each  of  the  latter  is  thus 
surmounted  apparently  by  a  small  elevation.  Here 
again  the  circinate  arrangement  may  be  conspicuous. 
In  other  cases  the  mouths  of  the  orifices  of  the 
pilosebaceous  crypts  are  the  seat  of  the  disorder ;  in 
others  the  scalp  becomes  the  site  of  a  seborrhceal  flux, 
the  secretion  drying  into  light  crusts  superimposed  upon 
a  macular  exanthem,  the  color  of  the  latter  often  being 
displayed  beyond  the  border  of  the  incrustation. 

In  special  cases,  notably  those  where  the  subject  of 
the  disease  has  a  skin  of  the  type  prone  to  exhibit  seba- 
ceous gland  affections,  the  symptoms  of  syphilis  apparent 
on  the  face  and  chest  are  commingled  with  the  evidences 
of  a  dry  or  oily  seborrhcea.  In  these  cases  the  erythe- 
matous syphiloderm  may  be  developed  first,  and  exhibit 
later  the  signs  of  seborrhceic  trouble  ;  or  the  reverse  may 
be  noted — i.  c,  the  erythematous  macules  may  be  im- 
planted upon  the  thick,  greasy,  muddy-hued  skin  of  the 
seborrhceic  patient.  In  these  instances  the  elevation  to 
a  slight  degree   of  the  patches,  the  greasy  scales,  and 


SYPHILIS    OF   THE   SKIN.  S1/ 

the  frequent  cap  of  yellowish  smegma  spread  over  the 
scalp  are  all  significant  in  connection  with  the  classical 
signs  of  early  syphilis.  An  early  form  of  alopecia  often 
coexists  with  this  catarrhal  condition  of  the  scalp. 

An  interesting  variation  of  the  erythematous  syphilo- 
derm  occurs  in  an  annular  or  ringed  form,  which  is 
always  conspicuous  when  it  develops  on  the  face.  It  is 
then  often  vividly  displayed  in  circlets  about  the  lips  and 
chin  or  the  brows,  with  frequent  involvement  of  the 
angles  of  the  lips  and  the  sulci  on  either  side  of  the 
nares.  This  eruption  may  also  cover  the  chest  and  the 
extremities,  and  prove  more  rebellious  to  treatment  and 
endure  for  a  greater  period,  than  the  simpler  form  of  the 
exanthem. 

The  macular  syphiloderm  may  relapse  under  ineffi- 
cient treatment  in  one  or  several  efflorescences,  but,  as  a 
rule,  it  appears  in  typical  development  but  once  in  a 
syphilitic  history.  The  evolution  of  what  is  often  thought 
to  be  a  late  macular  syphiloderm,  occurring  two  and 
more  years  after  infection,  is  an  eruption  which  has 
erroneously  been  supposed  to  be  due  to  syphilis.  In 
these  supposed  "  late  "  cases  there  is  developed  over  the 
surface  of  the  chest,  and  at  times  on  the  belly  and  else- 
where, multiple,  usually  coin-sized,  oval,  elliptical,  super- 
ficial patches,  scaling  very  slightly  at  the  periphery,  and 
with  a  clear  centre.  They  are  usually  brownish-red  or 
purplish-red  in  hue ;  they  have  been  noted  as  rebel- 
lious to  the  treatment  indicated  by  the  disease  present. 
Most  of  these  are  instances  of  pityriasis  maculata  et 
circinata,  "  pityriasis  rosea  "  of  authors.  In  the  spring 
and  the  autumn  many  of  the  subjects  of  syphilis  are 
peculiarly  susceptible  to  this  somewhat  rare  disorder, 
whose  innocent  lesions  commonly  disappear  in  a  brief 
time  under  the  influence  of  a  tonic  regimen,  well  com- 
bined with  the  use  of  the  cinchona  preparations  and  the 
salicylates. 

Purpuric. — Hemorrhage  into  the  several  portions 
of  the  integument  occasionally  complicates  not  merely 


88         SYPHILIS  AND    THE   VENEREAL    DISEASES. 

the  erythematous  but  also  other  syphilodermata,  such 
as  papules  and  bullae.  In  these  cases  the  occurrence 
of  pin-head  and  larger  purplish  and  mulberry-shaded 
spots  that  refuse  to  disappear  under  pressure  indicates 
that  the  coloring  matters  of  the  blood  have  been  ef- 
fused through  the  tunics  of  the  vessels.  It  is  to  be 
remembered,  in  all  cases  of  syphilis  where  iodide  of 
potassium  has  been  administered  for  the  relief  of  the 
disease,  that  this  drug  is  capable  of  producing  purpura 
of  the  skin,  especially  of  the  lower  extremities.  In 
some  instances  large  disks  and  even  wide  areas  of 
purpuric  maculation  are  produced  in  both  early  and 
late  periods  of  the  disease.  This  symptom  is,  however, 
most  commonly  seen  in  the  inherited  forms  of  the  dis- 
ease, though  it  is  not  rare  in  adults.  When  due  directly 
to  the  disease,  and  not  to  a  drug  administered  for  its 
relief,  it  should  be  viewed  as  a  somewhat  grave  symp- 
tom. It  accompanies  several  of  the  paraplegic  and 
hemiplegic  complications  of  nervous  syphilis. 

Anatomy. — Section  of  a  macular  lesion  exhibits 
merely  effusion  between  the  component  parts  of  the 
upper  corium,  with  some  displacement  and  elongation 
of  the  fibres  of  which  it  is  composed.  The  capillaries 
are  distended,  and  both  within  and  without  are  encum- 
bered with  round  and  spindle-shaped  cells.  The  acces- 
sory portions  of  the  skin  lying  in  the  upper  part  of  the 
corium  (sebaceous  and  pilary  crypts)  participate  some- 
what in  the  process,  but  the  sweat-glands  in  the  deeper 
portion  are  unaffected  (Crocker,  Neumann,  Biesiadecki, 
and  others). 

Diagnosis. — The  macular  syphiloderm  is  distin- 
guished from  the  eruptions  accompanying  exanthema- 
tous  fevers  by  the  features  described  above,  as  also  by 
the  temperature-changes  perceptible  in  such  fevers.  In 
case  of  syphilitic  fever  other  evidences  of  a  systemic 
infection  are  commonly  observed  (adenopathy  of  the 
post-occipital  and  other  glands ;  mucous  patches  of 
the  mouth,  anus,  or  vulva ;   alopecia ;    crusts  upon  the 


SYPHILIS   OF   THE   SKIN.  89 

scalp,  etc.).  In  the  medicamentous  rash  due  to  copaiba 
there  is  commonly  excessive  itching ;  this  and  other 
rashes  due  to  drug-ingestion  promptly  disappear  on  the 
withdrawal  of  the  exciting  cause.  In  tinea  versicolor 
the  presence  of  the  vegetable  parasite  and  the  distinct 
limitation  of  the  eruption  to  the  regions  covered  by  the 
clothing  are  important  points  of  difference.  The  color 
of  the  eruption — a  very  distinct  fawn  shade  or  deeper 
tint — never  has  the  reddish-brown  hue  of  the  syphilo- 
derm.  Pityriasis  maculata  et  circinata  is  usually  much 
less  abundantly  distributed,  and  its  patches  are  always 
in  ovals,  commonly  on  the  front  and  back  of  the  chest 
and  the  shoulders,  with  scaling  at  the  periphery  of  the 
clear  centre,  and  displaying,  when  on  the  chest,  an  ar- 
rangement of  patches  with  the  long  axis  at  right  angles 
to  the  vertical  line  of  the  body. 

The  prognosis  of  the  macular  syphilodermata  is  in 
general  favorable,  and  no  gravity  need  be  argued  from 
either  their  profuseness  or  their  deep  shade  of  color. 

II.  Papules. 

It  has  been  shown  that  papules  are  among  the  most 
common  of  the  syphilodermata.  Their  grouping,  color, 
situation,  and  environment  in  many  cases  of  syphilis  are 
so  characteristic  as  to  be  absolutely  diagnostic  of  the 
disease.  They  may  appear  at  any  time  from  the  third 
month  to  the  conclusion  of  the  first  year,  and  even  much 
later ;  they  may  develop  in  crops  ;  they  may  immediately 
spring  from  a  preceding  macular  exanthem,  or  succeed 
the  latter  after  an  interval ;  and  they  are  usually  sym- 
metrical in  the  earlier  and  asymmetrical  in  the  later  of 
the  periods  named.  They  vary  in  size  from  a  pin's  head 
to  that  of  a  bean,  and  may  be  multiple  or  few,  dis- 
seminate or  grouped,  generalized  or  limited  to  distinct 
regions  of  the  body,  conical  or  flat,  dry  or  moist,  in 
color  shading  from  a  light  crimson  to  a  dull  copper. 
They  may  scale  at  the  apex  or  be  surrounded  by  a  col- 
larette of  scales  at  the  base. 


90         SYPHILIS  AND    THE  VENEREAL   DISEASES. 

Papules  represent  the  syphilitic  process  in  the  skin 
and  the  mucous  membranes,  beginning  with  an  indolent 
inflammatory  process  in  the  corium,  inducing  a  thicken- 
ing of  the.  rete,  some  effusion  of  lymph-cells,  and  a  break- 
ing away  of  the  horny  layers  of  the  epidermis  from  the 
summit  of  the  circumscribed  inflammatory  product 
where  the  thickening  of  the  skin  occurs.  As  this 
change  may  involve  different  regions  of  the  body,  gross 
results  are  obtained,  whose  differences  depend  largely 
upon  the  site  of  each  lesion.  Papules  upon  the  scalp, 
for  example,  are  usually  dry  and  scaly ;  when  picked  or 
scratched  they  often  bleed  and  crust.  Upon  the  exposed 
and  dry  surface  of  the  skin,  such  as  the  extensor  faces 
of  the  extremities,  they  are  usually  acuminate,  dry,  and 
squamous.  On  the  brow,  near  the  border  of  the  hairs 
of  the  scalp,  they  often  surround  themselves  with  a  deli- 
cate collarette  of  dirty  scales,  exposing  a  copper-tinted 
integument  beneath  and  around  the  individual  papules, 
the  group  being  so  characteristic  as  to  have  gained  the 
title  of  the  "  corona  veneris." 

When  papules  form  upon  apposed  surfaces,  such  as  the 
skin  covering  the  voluminous  breasts  falling  over  the 
thorax  in  women,  or  the  folds  of  the  nates  in  contact,  or  the 
scrotum  lying  next  the  integument  of  the  thigh,  papules 
enlarge,  flatten,  secrete,  and  in  many  cases  produce  a 
sensation  of  itching.  Papules  forming  upon  mucous  sur- 
faces also,  by  reason  of  the  heat,  moisture,  and  friction 
to  which  they  are  subjected,  become  flattened  and 
secrete,  forming  thus  the  mucous  patch.  Papules  de- 
veloping upon  or  beneath  the  thick  epidermis  of  the 
palms  and  the  soles  of  adults  are  so  bound  down  that 
they  rarely  rise  above  the  general  level,  but  the  cracking 
of  the  scarf-skin  at  the  level  of  the  thickened  subepi- 
dermic  focus  produces  a  characteristic  scaling  of  the 
skin  in  the  regions  named. 

Dry  Papules. — [a)  Miliary  Papules. — -This  abundant 
efflorescence  is  less  frequently  noted  than  other  of  the 
papular  syphilodermata,  for  the  reason  that  its  very  pro- 


Plate  4. 


Small  papular  syphiloderm  (Stelwagon). 


SYPHILIS    OF   THE   SKIN.  9 1 

fuseness  argues  a  neglected  or  ignored  condition  of  the 
subject  of  the  disease  in  its  prior  manifestations.  Since 
these  neglected  and  ignored  patients  are  often  women, 
the  eruption  is  somewhat  more  often  observed  in 
them.  The  lesions  are  pin-head-sized,  closely-com- 
mingled, conical  or  rounded,  occasionally  umbilicated 
papules,  symmetrically  arranged,  often  widely  dispersed, 
and  even  generalized,  at  times  distinctly  and  even  ele- 
gantly grouped  in  circles  or  segments  of  circles,  light 
reddish  to  deep  crimson  in  shade,  the  apex  of  each 
papule  at  times  surmounted  by  a  still  finer  vesicle  con- 
taining a  droplet  of  serum — an  accident  which  usually 
points  to  a  coincident  febrile  access.  Involution  occurs 
by  fine  scaling  at  the  apex  of  each  lesion  and  flattening 
of  the  papules  to  a  dull,  purplish-red  maculation  of  the 
surface.  In  rare  cases,  chiefly  of  public  patients,  this 
eruption  may  be  merely  the  preliminary  stage  of  a 
diffuse  pustular  syphiloderm.  At  times  it  can  be  seen 
that  the  lesions  are  limited  to  the  hair-follicles.  There 
are  few  cases  in  which,  when  the  eruption  is  at  all  well 
marked  over  the  face,  the  neck,  and  the  trunk,  groups 
of  much  larger  lesions,  to  be  described  below,  may  not 
be  seen  in  other  regions  of  the  body. 

Diagnosis. — The  coincident  symptoms  (mucous  patches, 
adenopathy,  etc.)  indicating  the  presence  of  a  disease 
accompanied  by  other  than  skin-involvement  usually 
suffice  for  the  establishment  of  a  diagnosis  in  these  cases. 
Scabies  and  ringworm,  the  former  due  to  an  animal  and 
the  latter  to  a  vegetable  parasite,  are  distinguished  by  the 
presence  of  the  exciting  cause  in  each  affection,  the  for- 
mer being,  as  a  rule,  accompanied  by  an  intense  and 
characteristic  pruritus,  the  latter  by  a  circinate  arrange- 
ment of  the  patches.  The  lesions  of  lichen  planus  are 
flattened  at  the  summit  and  usually  exhibit  polygonal 
outlines,  while  the  frequent  linear  and  angular  distribu- 
tion of  the  papules  is  never  seen  in  the  syphiloderm. 
Psoriasis  in  some  cases  strongly  resembles  a  scaling  and 
well-developed  papular  syphiloderm,  but  the  former  dis- 


Q2        SYPHILIS  AND    THE    VENEREAL   DISEASES. 

ease  is,  as  a  rule,  more  extensive,  and  the  scales  are  more 
abundant,  more  voluminous,  and  more  lustrous.  Kera- 
tosis pilaris  in  extreme  expression  over  the  limbs  and 
the  body  is  to  be  recognized  by  the  obvious  situation 
of  each  papular  lesion  at  the  orifice  of  the  pilosebaceous 
crypt. 

Prognosis. — The  course  of  the  eruption  in  healthy  sub- 
jects, whether  acutely  or  slowly  pursued,  is  toward  a 
favorable  termination.  At  times  the  eruption  proves 
intractable  to  treatment. 

(b)  Lenticular  Papules. — The  papules  are  here  usually 
discrete,  rounded  or  oval,  and  well-defined  in  contour, 
and  vary  in  size  from  a  pinhead  to  that  of  a  large 
bean  and  even  larger.  They  are  rarely  elevated  to 
any  extent  above  the  level  of  the  integument,  and 
at  times  they  are  so  flat  as  to  be  mistaken  for  mere 
unsightly  blotches  of  the  surface.  They  vary  in 
color  from  an  exceedingly  dull  to  a  bright  copper 
shade,  and  are  usually  remarkable  for  the  fringe  or  col- 
larette of  dirty  scales  fraying  away  from  their  base,  as 
described  in  connection  with  the  "  corona  veneris."  The 
eruption  may  appear  in  a  few  months  after  infection,  and 
then  disappear,  or  it  may  occur  in  crops  lasting,  with 
varying  intervals,  for  one  or  two  years  after  the  onset  of 
the  disease.  These  papules  are  among  the  commonest 
of  the  syphilodermata,  and,  with  variations  of  the  sort 
described  above  as  due  to  the  accidents  of  site  and 
environment,  probably  figure  in  a  modified  form  in  most 
of  the  lesions  which  are  to  be  observed  during  the  first 
two  years  after  infection.  The  eruption  spreads  both  by 
the  outcropping  of  new  lesions  and  by  the  enlargement 
of  individual  papules  in  situ,  the  latter  being  rather  more 
common.  As  resolution  occurs  the  papule  flattens  to 
the  level  of  the  skin,  leaving  merely  a  pigmented  macule 
as  a  relic  of  its  existence.  These  pigmented  patches, 
especially  over  the  face,  are  apt  to  be  exceedingly  re- 
bellious to  treatment  and  slow  to  disappear,  much  to  the 


Plate  5. 


Papular  syphiloderm,  orbicular  grouping  (Mracek). 


Ltih .  Arts!  F.  Heichtwld,  Munchen . 


SYPHILIS   OF   THE   SKIN.  93 

chagrin  of  the  patient,  who  speedily  comes  to  a  realiza- 
tion of  their  peculiar  significance. 

The  eruption  may  be  quite  general  at  the  first,  and 
later  may  limit  itself  to  a  favorite  locality,  such  as  the 
forehead,  the  back  of  the  neck,  the  belly,  the  buttocks, 
the  flexor  aspects  of  the  joints,  the  scrotum,  and  the 
outer  face  of  the  labia  majora. 

It  is  the  modification  by  grouping  and  coalescence  of 
the  papular  syphiloderm  that  produces  the  sub-varieties 
recognized  by  authors  as  "  nummular  "  and  "  corymbi- 
form."  In  the  former  the  papules  enlarge  to  fiat  disks 
of  the  size  of  large,  and  even  of  the  largest,  coins,  cir- 
cumscribed, and  with  depressed  crateriform  centres,  the 
contrast  between  the  central  area  and  the  circumvalla- 
tion  of  the  smooth,  copper-tinted  ring  being  conspicu- 
ous. In  the  corymbiform  arrangement  satellite-like 
groups  develop  about  the  central  disk.  Other  odd- 
looking  forms  are  the  result  of  different  groupings  of 
the  coalesced  or  isolated  papules,  as  in  the  shape  of  the 
letter  S,  of  a  kidney,  etc. 

Midway  between  papules  and  purely  squamous  le- 
sions in  syphilis  stand  the  papulo-squamous  syphilo- 
dermata,  lesions  in  which  the  characteristically  developed 
and  situated  papules  of  syphilis  undergo  a  squamous 
transformation  at  the  summit,  where  a  little  heap  of 
dirty-looking,  adherent,  sometimes  friable,  but  often  cor- 
neous scales  accumulates.  This  combination  of  scales 
and  papules  has  been  thought  to  resemble  psoriasis,  but 
the  correspondence  is  rarely  suggested  to  the  trained 
eye,  for  the  elevation  of  the  lesions,  the  character  of  their 
scales,  and  the  color  of  the  dull-tinted  papules  on  which 
they  rest  are  significant.  The  circular  outline  of  many 
of  the  confluent  patches  of  the  larger  papulo-squamous 
disks  and  of  psoriatic  patches  in  general  is  often  confus- 
ing, and  yet  the  bulkier  and  dirty-looking  scales  of  the 
syphiloderm,  the  dull,  ham-colored  patch  in  the  centre 
of  the  circinate  group,  often  slightly  infiltrated  or  thick- 
ened, offer  a  strong  contrast  to  the  more  vivid  hues  of 


94        SYPHILIS  AND    THE  VENEREAL   DISEASES. 

psoriasis.  The  clear-tinted  and  uniformly  spread  scales 
of  the  psoriatic  patch,  its  centre  either  evenly  thatched 
with  such  scales  or,  if  quite  clear,  showing  only  a  slightly 
shaded  and  non-infiltrated  epidermis,  are  also  to  be  con- 
sidered in  establishing  a  differential  diagnosis.  Over 
the  face  the  papulo-squamous  syphiloderm  is  often  cov- 
ered with  a  mealy  or  granular  mass  of  scales  of  a  dirty 
grayish  hue,  this  character  of  the  exuvium  being  due  to 
admixture  with  a  desiccated  sebaceous  product. 

Diagnosis. — The  differences  between  psoriasis  and 
syphilitic  papulo-squamous  eruptions  are  of  importance. 
It  is  only  atypical  manifestations  of  either  disorder  that 
are  liable  to  be  confounded.  The  reddish  and  bleeding 
surface  left  on  removal  of  the  scales  from  a  psoriatic 
patch  is  never  exactly  reproduced  in  syphilis,  and  the 
localization  of  the  former  on  the  extensor  surfaces  of 
the  extremities  is  never  characteristic  of  the  syphilitic 
exanthem.  Seborrhceic  affections,  particularly  of  the 
face,  resemble  the  scaling  papular  syphiloderm  in  the 
matter  of  the  greasy  crust  with  which  they  are  covered 
and  the  generally  dirty  aspect  of  the  patch,  but  the  cir- 
cinate  contour  of  the  syphiloderm,  never  seen  in  the  sebor- 
rhceic disorder  (save  in  exceptional  cases  on  the  trunk), 
and  the  characteristic  copper  hue  of  the  surface  beneath 
the  scales,  sufficiently  distinguish  the  syphilitic  exanthem. 

In  almost  all  the  syphilitic  patches  resembling  those 
of  either  psoriasis  or  seborrhcea  the  infiltration  of  the 
body  of  the  patch,  with  its  higher  wall  of  infiltration  at 
the  periphery,  is  evident  on  examination. 

Palmar  and  Plantar  Syphilodermata  (Palmar  and 
plantar  "syphilitic  psoriasis,"  etc.). — The  papules  of 
syphilis,  when  developing  upon  the  palms  and  the 
soles,  have,  as  already  shown,  not  only  a  characteristic 
aspect  and  career,  but  are  rarely  to  be  confounded  with 
other  disorders.  The  peculiarity  of  the  papule  in  this 
situation  is  that  it  is  developed  within  and  beneath 
the  dense  and  voluminous  corneous  envelope  of  these 
regions,  and  hence  fails  to  produce  either  a  conical  or 


SYPHILIS   OF   THE   SKIN.  95 

flattened  elevation  above  the  surface ;  it  produces  in- 
stead a  circumscribed  thickening  of  the  skin,  which  in 
the  epidermal  portions  scales,  and  in  extreme  cases  in- 
duces an  ulceration  in  the  region  of  each  papular  thick- 
ening. These  eruptive  symptoms  are  often  early  to 
appear,  and  sometimes  they  linger  after  years  have 
elapsed  as  almost  the  sole  symptoms  of  the  disease. 
They  are  much  more  common  than  is  generally  believed 
in  the  early  periods  of  the  malady — that  is,  within  three 
months  after  infection — being  usually  recognized  in  some 
form  by  the  expert  when  they  escape  the  attention  of  all 
others,  even  of  the  patient.  They  occur  usually  sym- 
metrically, involving  both  hands  and  feet,  in  the  earlier 
manifestations,  and  asymmetrically  in  later  stages,  when 
either  the  feet  alone  or  the  hands  alone,  or  even  but  one 
palm  or  one  sole,  is  attacked.  As  a  rule,  they  occur  at 
first  in  circumscribed  points,  and  the  tendency  is  in 
general  toward  a  diffuse  thickening  of  the  entire  integu- 
ment of  the  palm  or  sole.  Instances  are  not  very  rare 
in  which,  with  few  other  evidences  of  the  disease,  six 
and  eight  years  after  infection  a  single  palm  exhibits  a 
squamous  syphiloderm,  having  displayed  this  symptom 
with  slight  variations  for  a  series  of  years.  In  all  the 
regions  named  the  influence  of  the  employment  of  the 
hands  in  labor  is  usually  striking,  the  right  hand  being 
worse  or  solely  involved  in  right-handed  patients,  and 
the  feet  worse  in  those  who  stand  or  walk  much  in  the 
day ;  but  marked  exceptions  occur. 

In  its  simplest  expression  the  epidermis  of  the  region 
involved  displays  merely  split-pea  to  lentil-sized  dis- 
colorations  productive  of  no  sensation  by  which  the 
patient  is  made  conscious  of  their  existence.  The  centre 
of  the  palm  or  the  inner  face  of  the  instep  is  usually  first 
affected,  and  the  spots  may  be  either  discrete  and  with- 
out apparent  order  as  to  grouping,  or  develop  in  arcs  of 
circles  to  be  distinctly  or  dimly  discerned.  From  these 
points  they  may  spread  to  the  dorsum  of  the  hands  and 
the  feet,  even  over  the  dorsum   of  the  digits,  but   in  all 


96         SYPHILIS  AND    THE  VENEREAL  DISEASES. 

such  instances  the  extension  from  the  palmar  or  plantar 
to  the  dorsal  surface  can  be  determined  without  effort. 
In  this  way  the  extension  may  be  toward  the  interdigital 
spaces  and  the  wrists  and  the  ankles,  the  squamous 
process  being  in  obvious  relation  with  that  first  invad- 
ing the  palmar  or  the  plantar  area.  When  the  digits 
alone  are  involved,  the  flexor  aspect  is  always  chiefly 
implicated,  and  here,  as  also  in  the  palms  and  the  soles, 
the  natural  folds  and  furrows  of  the  skin  furnish  often  a 
special  territory  for  the  incursions  of  the  malady. 

As  the  disease  advances,  both  in  time  and  in  degree 
of  involvement  of  the  integument,  the  maculae,  of  a  ham- 
red  shade,  furnish  from  the  surface  of  each  a  slight 
exfoliation,  which,  as  the  disorder  advances,  becomes  a 
true  scaling,  the  epidermis  being  lifted  away  centrally,  so 
as  to  produce  about  the  morbid  spot  a  dirty-looking, 
ragged  fringe  of  epidermis.  An  advanced  stage  of  the 
disease  is  that  where,  usually  in  consequence  of  manual 
labor,  friction,  and  exposure  of  the  hands  to  soil,  water, 
or  chemicals,  fissures  result ;  these  fissures  make  inef- 
fectual attempts  at  healing,  forming  a  new  and  tender 
epidermis  which  floors  over  the  crack  in  the  skin,  only 
in  turn  to  give  way  and  be  supplanted  by  succeeding 
fissures  and  new  formations  of  epidermis  until  a  palmar 
or  plantar  ulcer  or  an  ulcerated  fissure  is  excavated,  bor- 
dered by  successive  plateaux  of  newer  or  older  skin,  the 
outer  edge  being  represented  by  large,  partly-detached, 
and  ragged  flakes  of  epidermis  whose  angular  indenta- 
tions or  scallops  roughly  resemble  the  fracture  of  a  pane 
of  glass  by  a  missile  projected  through  its  substance. 
Deeply  ulcerated  and  exquisitely  painful  lesions  of  this 
class  are  more  often  palmar  than  plantar,  by  reason  of 
the  use  of  the  hands  in  labor ;  but  the  feet  of  those  who 
toil  in  sewer-digging,  road-making,  etc.  suffer  to  a 
similar  extent. 

In  certain  patients,  early  or  late  in  the  course  of  the 
disease — usually  the  former — the  palmar  syphiloderm  is 
declared   in   the   form   of  numerous  split-pea-sized  and 


Plate  6. 


\        # 


# 


# 


Papular  plantar  syphiloderm  (Mracek). 


Lith.Ansl  E Reic/itiold.  Munchen. 


SYPHILIS    OF   THE   SKIN.  97 

circumscribed  corneous  accumulations,  unproductive  of 
subjective  sensations.  These  grain-like  masses  may  be 
dug  with  the  point  of  a  knife  from  their  bed,  usually 
without  the  production  of  pain.  The  pits  thus  left  in 
the  epidermis  may  be  first  seen  by  the  practitioner, 
representing  then  the  several  sites  whence,  by  accident 
or  intentionally,  the  minute  corn-like  masses  have  been 
removed.  There  may  be  few  or  many  of  such  minute 
lesions  in  the  palm ;  in  the  latter  event  the  organ 
comes  to  resemble  in  a  high  degree  the  site  of  a  sym- 
metrical palmar  and  plantar  keratosis,  a  disorder  wholly 
unconnected  with  the  syphilitic  process. 

In  all  the  squamous  syphilodermata  of  the  palmar 
and  plantar  regions  there  are  two  features  never  to  be 
ignored  by  the  diagnostician.  The  first  is  the  palpable 
fact  that  all  the  scales  in  these  regions  are  sequences  of 
abortive  or  developed  infiltrations,  papules,  or  tubercles 
of  the  part.  The  second  is  that  the  tendency  of  the 
eruptions  of  syphilis  to  assume  the  outlines  of  a  whole 
or  a  part  of  a  circle  is  well  displayed  over  the  palm  and 
sole.  At  times  the  circles  are  to  be  seen  very  perfectly 
outlined,  in  many  small  or  large  groups  in  a  single 
palm ;  again,  the  entire  diffused  patch,  made  up  of 
coalesced  macules  or  flat  papules,  has  a  defined  circular 
border,  evident  in  its  advance  toward  the  wrist  or  the 
line  of  the  fingers,  sweeping  toward  the  dorsum  of  hand 
or  foot,  or  well  exhibited  in  the  lines  drawn  between  the 
web  of  the  fingers  or  running  over  the  hypothenar 
eminence.  An  example  of  this  tendency  may  be  con- 
spicuous in  the  thinner  integument  of  the  inner  face  of 
the  arch  of  the  foot,  where  a  circlet  can  often  be  dis- 
cerned extending  from  exceedingly  dense  corneous 
plates  of  the  sole. 

Diagnosis. — Eczema  of  the  hands  and  the  feet  usually 
involves  the  dorsum,  or,  if  the  sole  or  the  palm  at  all, 
only  by  extension  to  the  latter  from  the  former  region. 
Eczema  limited  to  the  palms  and  the  soles  does,  how- 
ever, occur,  but  chiefly  in  adults  whose  organs  are  more 

7 


98        SYPHILIS  AND    THE    VENEREAL   DISEASES. 

or  less  continually  immersed  in  water,  especially  water 
charged  with  mineral  constituents.  Patients  of  this 
class  are  usually  dyers,  laundresses,  bar-keepers,  or  men 
engaged  at  soda-water  fountains.  The  infiltrated  areas 
of  eczema  are  never  well  defined  save  in  eczema  mar- 
ginatum of  this  region ;  the  involvement  of  the  skin  is 
much  more  uniform ;  there  is  apt  to  be  pustulation  and 
vesiculation ;  there  is  never,  under  any  circumstances, 
ulceration,  even  when  the  eczematous  fissures  are  most 
painful ;  and  the  itching  is  apt  to  be  well  marked. 
Psoriasis  is  said  to  be  in  very  rare  cases  limited  to  the 
palms  and  the  soles,  but  these  exceptions  are  so  few  as 
simply  to  prove  the  rule.  In  any  doubtful  case  the  dis- 
covery of  psoriatic  patches  on  the  scalp,  the  sacrum,  the 
elbows,  or  the  knees  would  determine  the  question.  It 
has  been  said  that  syphilis  of  the  palms  and  the  soles  is 
ever  accompanied  by  some  unexpected  lesion  elsewhere, 
and  it  is  often  true  that  a  mucous  patch  in  the  mouth  or, 
in  advanced  cases,  an  undeveloped  gumma  of  the  leg 
will  reward  the  careful  explorer  for  his  pains. 

Moist  Papules. — (a)  Mucous  patches  (Mucous  plaques ; 
Plaques  muqueuses). — The  patch  which  is  seated  upon  the 
mucous  membranes  in  syphilis  is  pathologically  identi- 
cal with  the  mucous  plaque  or  the  moist  papule  of  the 
skin.  In  both  cases  the  papule — which  in  the  palm  or 
the  sole  fails  to  become  elevated,  but  flattens  to  the  point 
of  exhibiting  merely  a  scaling  and  plane  macule — shows, 
in  the  regions  of  moisture,  of  friction  or  apposition  of 
contiguous  surfaces,  and  of  heat,  merely  an  oval  or  circu- 
lar, scarcely  elevated  lesion.  Its  summit  either  furnishes 
a  mucoid  secretion  or  displays  a  thin  pellicle  more  or  less 
firmly  attached,  representing  a  sodden  epidermal  plate 
not  as  yet  loosened  from  its  underlying  attachments. 

Moist  papules  of  the  skin  in  syphilis  occur  in  regions 
where  the  conditions  are  similar  to  those  of  mucous 
membranes  with  respect  to  heat,  moisture,  and  the  appo- 
sition of  surfaces,  as  between  the  breasts  of  women, 
between  the  nates,  in  the  axillae  and  the  groins  of  fleshy 


SYPHILIS  OF  THE   SKIN.  99 

persons,  and  in  the  interdigital  spaces.  Here  the  lesions 
form  flattened  disks,  slightly  elevated  above  the  general 
level,  covered  with  a  whitish  or  grayish  pellicle,  often 
slightly  depressed  in  the  centre,  and  looking  not  unlike 
one  of  the  varieties  of  the  soft  corn.  At  times  they  have 
a  reddish  tint.  They  are  generally  moist,  secreting  a  thin 
mucus  which  in  warm  weather  and  in  the  uncleanly  has 
a  fetid  odor.     These  lesions  are  decidedly  more  common 


Fig.  1. — Moist  papules  (after  Miller). 

in  women  than  in  men,  and  in  the  young  adult  rather 
than  in  the  middle-aged.  Occasionally  they  develop 
into  large  vegetating  masses ;  at  other  times  they  ulcer- 
ate. Their  secretion  is  highly  contagious.  There  is  no 
better  illustration  of  the  moist  papule  than  the  chancre 
of  the  mucous  surface  of  the  prepuce,  which,  having  sur- 
vived until  general  symptoms  of  systemic  disease  occur, 
undergoes  a  characteristic  transformation  in  situ  into  a 
moist  papule. 

(b)  Condylomata  (Condylomata  lata;  Verruca  acumi- 
nata ;  Moist  wart ;  Venereal  wart ;  Ger.  Spizen  Warzen). 
— Condylomata  are  simply  moist  papules  which  undergo 
a  hyperplastic  metamorphosis  in  consequence  of  the 
extremely  favorable  circumstances  under  which  they 
develop.  Thus,  a  recently  infected,  young,  fleshy  pros- 
titute of  the    filthy    class    is    exceedingly  apt   to    dis- 


IOO      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

play  lesions  of  this  sort  about  the  vulva  and  the  peri- 
neum. There  are  two  tolerably  distinct  types  of  this 
affection,  namely,  the  flat  condyloma  and  the  pointed 
wart.  Both  occur  in  syphilitic  subjects,  but  the  former 
is  seen  only  in  that  disease  and  is  a  distinct  symptom  of 
it;  the  latter  is  seen,  when  the  conditions  are  favorable,  not 
only  in  syphilis,  but  in  other  venereal  diseases  as  well. 

Condylomata  are  found  in  the  regions  favorable  to  the 
growth  of  all  moist  papules,  but  they  are  best  seen 
about  the  anus,  where  they  often  encircle  the  anal  orifice 
with  broad  flattened  disks  from  the  size  of  coins  to  that 
of  the  section  of  a  large  egg.  They  enlarge  by  the 
growth  of  the  primary  lesions  and  also  by  coalescence 
of  the  disks.  They  have  a  disgusting  odor,  they  generally 
secrete  a  mucoid  or  even  a  puriform  semi-fluid,  and  they 
are  whitish  both  from  this  secretion  and  from  the  pelli- 
cle covering  their  broad  surface.  They  are  capable  of 
self-multiplication,  the  lying  of  one  disk  against  an 
exposed  surface  being  at  times  sufficient  to  produce  a 
similar  lesion  exactly  at  the  point  of  contact.  As  dis- 
tinguished from  others  of  the  syphilodermata,  they  are 
usually  the  seat  of  a  tormenting  pruritus. 

The  pointed  wart  occurs  in  the  subjects  of  syphilis 
and  also  in  those  whose  parts  are  bathed  with  blennor- 
rhagic,  leucorrhoeal,  and  other  secretions  not  syphilitic. 
They  are  single,  multiple,  often  exceedingly  numerous, 
filiform,  papilliform,  or  corymbiform,  moist  and  pointed 
lesions  varying  in  size  from  a  pin-point  to  that  of  a  fist,  and 
even  in  extreme  cases  very  much  larger,  the  large-sized 
masses  being  always  compounded  of  many  primary 
warts,  the  septa  between  which  can  be  recognized  divid- 
ing the  compound  mass  into  separate  lobes.  They  are 
often  smeared  with  mucus,  after  the  removal  of  which 
can  be  seen  their  vivid  red  color,  each- separate  apex  being 
provided  with  a  delicate  tuft.  They  are  often  compared 
in  appearance  to  the  comb  of  a  cock.  They  rarely 
occur  in  virgins,  but  at  times  they  develop  in  pregnancy, 
disappearing,  as  a  rule,  after  delivery.     Cocci  and  bacilli 


Plate  7. 


SYPHILIS   OF   THE  SKIN.  101 

have  frequently  been  recognized  upon  their  surface. 
They  bleed  readily  and  freely  when  torn,  scraped,  or 
wounded  by  accident. 

Pathologically,  all  moist  papules  are  to  be  viewed  as 
hyperplasias  of  the  epidermis  occurring  under  the  influ- 
ence of  the  syphilitic  process ;  the  pointed  warts  are  not 
in  all  cases  strictly  defined  syphilodermata,  but  are 
growths  occurring  under  peculiarly  favorable  circum- 
stances in  the  situations  described.  These  growths  are 
impressed  with  the  syphilitic  mode  when  occurring  in 
the  syphilitic  subject.  Anatomically  they  are  found  to 
be  built  up  chiefly  of  thickened  and  enlarged  rete-cells, 
the  corium  and  the  papillary  layer  exhibiting  cellular  in- 
filtration, the  papillae  reaching  upward  by  elongations 
between  the  wide  fields  of  the  rete-pegs  dipping  be- 
tween the  papillary  eminences. 

Diagnosis. — Pemphigus  vegetans  (of  Neumann)  often 
occurs  first  about  the  vulva  and  the  anus.  Its  lesions 
have  frequently  been  mistaken  for  condylomata.  Close 
study  will,  however,  reveal  that  the  vegetating  masses  in 
pemphigus  spring  from  the  sites  of  bullae,  that  they  are, 
as  a  rule,  more  closely  packed  together,  and  that,  instead 
of  furnishing  a  mucoid  secretion,  they  are  bathed  in  a 
more  profusely  furnished  fluid,  which,  as  a  rule,  is  desti- 
tute of  any  offensive  odor.  There  is  less  flattening  of 
the  pemphigoid  eminences ;  and  when  similar  lesions 
occur  in  the  mouth,  the  latter  are  to  be  distinguished 
from  mucous  patches  by  their  extreme  soreness  and 
by  the  fact  that  in  the  latter  situation  they  begin  as 
blebs.  In  pemphigus  vegetans  there  may  be  fever;  and 
the  signs  of  an  exceedingly  grave  involvement  of  the 
system  are  usually  present. 

III.  Pustular  Syphilodermata. 

It  has  been  seen  that  the  type  of  the  lesion  of  syphilis 

in  the  skin  is  to  be  recognized  in  the  papule.     This  may 

spring  from  a  macular  lesion  or  be  such  ab  initio,  but 

whether  the  one  or  the  other,  or  whether  the  further 


102      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

evolution  be  in  the  line  of  the  squamous  syphiloderm 
of  the  palm  or  of  the  moist  condyloma  of  the  vulva, 
in  all  these  cases  the  career  of  the  syphilitic  affection 
may  be  described  as  pursued  within  natural  parallels. 
When,  however,  vesicles,  pustules,  or  blebs  appear,  it 
may  in  general  be  believed  that  some  accident  has  inter- 
vened to  divert  that  career  into  singular  channels.  These 
accidents  are,  briefly,  first,  medicaments  employed  for 
the  treatment  of  the  disease,  productive  of  medicament- 
ous  rashes  in  the  subject  of  syphilis ;  second,  the  inva- 
sion of  the  skin  by  staphylococci  (staphylococci  pyo- 
genes albus  et  aureus) ;  or,  lastly,  neglect  or  abuse  of 
the  skin,  as  in  case  of  extreme  filth,  the  application 
externally  of  injurious  medicaments,  and  the  attacks  of 
animal  parasites  (fleas,  bugs,  lice,  etc.).  It  is  an  inter- 
esting and  noteworthy  fact  that  the  great  number  of  all 
pustular  eruptions  in  syphilis  are  observed  in  public  and 
hospital  patients.  It  is  among  the  rarest  of  occurrences 
to  find  patients  of  the  well-to-do  class,  properly  treated, 
exhibiting  these  symptoms  of  the  disease.  These  erup- 
tions have,  however,  been  so  long  classed  with  the 
exanthemata  due  exclusively  to  syphilis  that  some  bold- 
ness is  needed  to  relegate  them  strictly  to  the  category 
in  which  they  belong.  They  have,  it  is  true,  the  syph- 
ilitic impress,  but  their  exciting  cause  is  an  accidental, 
and  not  an  essential,  factor  in  the  malady. 

Under  the  title  of  the  pustular  syphilodermata  are 
here  included  all  fluid-containing  lesions  of  the  skin, 
such  as  vesicles,  pustules,  and  bullae.  Many  of  these 
eruptive  phenomena  have  been  given  unfortunate  titles 
in  the  text-books,  such  as  "  varicella-form,"  "  eczema- 
tous,"  "  acne-form,"  etc.  These  names  should  all  be 
obliterated  from  the  nomenclature  of  syphilis ;  first, 
because  it  is  unwise  to  describe  one  disease  in  terms  of 
another  with  which  it  is  liable  to  be  confounded ;  sec- 
ond, because,  to  be  of  practical  value  in  the  way  of 
description,  a  title  should  have  a  fixed  meaning.  The 
words   "  eczema,"   "  impetigo,"   and    "  ecthyma,"   which 


Plate  8. 


<3 


Ov 


w- 


S     ■ 


.<;>) 


0         1 


^ 


# 


a 


Pustular  syphiloderm  of  the  face  (Mracek). 


/,/A     fr>c/   F  Rnirhhnlrl   Miinrh. 


SYPHILIS   OF   THE   SKIN.  103 

have  been  used  in  this  connection,  no  longer  describe 
classically  defined  symptoms  of  any  skin-anomaly,  but 
mean,  instead,  ranges  of  widely  differing  symptoms  due 
to  various  causes,  and  conveying  to  the  eye  no  such  fixed 
impression  as  these  names  are  supposed  to  produce  upon 
the  mind. 

Miliary  Pustular  Syphiloderm. — In  this  eruption 
pinhead-sized  pustules,  or,  more  properly,  vesico-pus- 
tules,  are  evolved,  each  at  the  summit  of  a  papule,  and, 
as  previously  suggested,  almost  always  as  the  result  of  a 
febrile  state  complicating  the  ordinary  evolution  of  the 
disease.  At  times  the  cause,  however,  as  in  the  other 
eruptive  disorders  of  this  class,  is  distinctly  due  to  a 
secondary  infection  with  the  toxines  of  staphylococci. 
The  lesions  are  pinhead-sized,  but  they  may  increase 
to  the  size  of  the  larger  pustules.  They  may  be  general- 
ized and  symmetrically  distributed,  or  more  rarely  few 
in  number  and  grouped,  developing  with  considerable 
rapidity  or  very  slowly.  They  are  often  commingled 
with  papules,  and  even  with  the  macules  of  the  erythe- 
matous syphiloderm.  At  times  they  have  a  circinate 
grouping;  at  other  times  they  are  disseminated  freely 
over  the  face,  the  trunk,  and  the  flexor  surfaces  of  the 
limbs.  In  exceedingly  rare  cases  the  eruption  is  gen- 
eralized. The  pustules  may  be  surrounded  by  a  char- 
acteristically tinted  areola,  and  they  may  disappear  by 
desiccation  of  the  effused  fluid  into  thin  brownish  or 
dark-colored  crusts,  or  there  may  be  coalescence  of  the 
pustules  to  the  point  of  formation  of  a  superficially  sup- 
purating surface.  The  color  of  the  base  of  the  pustules, 
and  of  the  intervening  skin  when  the  lesions  are  closely 
packed  together,  varies  from  a  brownish  to  a  dull  crimson 
hue,  changing  to  a  peculiar  dusky-brown  when  involu- 
tion is  in  progress.  The  firm,  shot-like  papules  on  the 
point  of  suppurating  at  the  apex  have  at  times  been 
mistaken  for  the  lesions  of  small-pox,  which  they  greatly 
resemble.  This  syphiloderm  is  frequently  recognized 
within  the  first  few  months  after  infection. 


104      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

It  is  somewhat  difficult,  and  from  a  diagnostic  point 
of  view  not  highly  important,  to  distinguish  between 
the  miliary  and  the  lenticular  pustules  of  syphilis,  since 
the  former  are  freely  convertible  into  the  latter,  and  the 
essential  difference  between  all  is  merely  the  degree  to 
which  in  each  the  minute  abscess  spreads  in  area  and  in 
depth.  In  the  one  class  or  the  other  are  evolved  the 
following  clinical  types  : 

I.  Pustules  situated  at  the  orifice  of  the  pilosebaceous 
crypt,  occurring  chiefly  where  those  accessories  of  the 
skin  are  largest  and  most  abundant  (scalp,  face,  and  upper 
chest).  In  these  regions  minute  or  even  large  bean- 
sized,  acuminate,  and  conical  or  flattened  pustules  form ; 
these  pustules  desiccate  into  thin  crusts  or  furnish  a 
superficial  area  of  pustulation.  The  cicatrices  left  are 
rarely  conspicuous  or  even  permanent;  more  distressing 
to  the  patient  is  the  brownish  stain  left.  The  lesions 
are  often  distinctly  grouped.     The  general  aspect  of  the 


Fig.  2. — Large  pustular  syphiloderm  (Stelwagon). 

region  thus  involved  (lips,  nose,  forehead,  etc.)  is  one  of 
extreme  dirtiness,  even  the  regions  of  the  skin  not  dis- 
playing eruptive  symptoms  being  unwholesome  in 
appearance  and  muddy  in  hue. 

2.  In  a  second  clinical  form  the  pustules  are  larger, 
usually  flatfish,  and,  after  attaining  the  size  of  a  pea  or 
that  of  a  large  bean,  surmount  superficial,  rarely  very 
deep,  circumscribed  ulcers  (Fig.  2).  Here  the  pus- 
formation  is  decidedly  more  abundant ;  the  copper- 
colored  or  even  chocolate-tinted  pigmentation  left  after 


Plate  9. 


<■?)• 


a 


fa^V- 


if-  *a „  sc 


- 


i 


5, 1'f'&j 


# 


- 

- 

$ 

Papulo-pustular  syphiloderm  (Mracek). 


IJlh.Anst  F.  Rpichhoid.  Muuchen . 


SYPHILIS   OF   THE  SKIN.  105 

involution  is  more  marked,  and  the  resulting  scars  are 
more  often  indelible. 

3.  In  a  confluent  variety  of  the  larger  pustular  lesions 
— as  a  rule,  flatfish  and  decidedly  fewer  in  number  than 
in  other  cases — there  is  distinct  circular  grouping  of  the 
pustules  and  the  underlying  ulcers.  After  fusion  of  the 
elements  of  the  eruption  an  ulcerating  ring  forms, 
usually  surmounted  by  a  dirty-brownish  crust,  often 
with  a  ham-tinted  stain  at  the  outer  border.  Here  heal- 
ing may  occur  at  one  or  several  points,  producing  thus 
alternations  of  crusts  and  newly-formed  epidermis  in  the 
ring  or  the  parts  of  a  ring  surrounding  either  an  integ- 
ument unaffected  centrally  or  a  healed  or  healing  ulcer. 

4.  Another  clinical  form  is  to  be  recognized  where  the 
lesions  are  few  and  are  not  irregularly  distributed  over 
the  entire  surface,  but  where  six  or  more  form  perhaps 
over  the  scalp,  or  a  similar  number  along  the  alae  of  the 
nose,  the  extensor  face  of  the  elbow,  or  over  the  genital 
region,  and  perhaps  none  elsewhere. 

Pustulo-crustaceous  or  Pustulo-ulcerative  Syphilo- 
dermata. — These  terms  represent  an  artificial  distinction 
preserved,  as  a  matter  of  convenience  merely,  in  classi- 
fying the  pustular  syphilodermata.  The  lesions  thus 
designated  represent  a  variation  in  the  line  of  ulcera- 
tion and  consequent  destruction  of  parts  deeper  than 
those  affected  in  more  superficial  erosions  (PI.  10).  The 
pustulo-crustaceous  syphilodermata  are  all  pathologically 
alike,  differing  chiefly  in  point  of  gravity.  Each  repre- 
sents a  secondary  infection  of  the  skin  with  cocci.  Of 
the  members  of  this  group  it  may  be  said  that  the  single 
or  sparse  lesions  are  commonly  more  destructive  than 
those  which  are  decidedly  multiple ;  that  in  point  of 
gravity  a  very  great  multiplicity  of  lesions  betokens  a 
gravity  dependent  upon  the  constitutional  effect  of  the 
involvement  of  a  large  portion  of  the  skin  in  an  ulcera- 
tive process ;  and  that  generally  the  amelioration  of  the 
condition  of  the  integument  is  proportioned  to  the  im- 
provement in  the  systemic  state  of  the  patient.     They 


106      SYPHILIS  AND    THE  VENEREAL   DISEASES. 


represent  in  general  a  somewhat  late  stage  of  syphilis,  and 
one  in  which  are  found  patients  who  are  cachectic,  poorly 
fed,  or  improperly  treated  or  cared  for  (PI.  1 1).  Here  the 
pustules  tend  to  enlarge,  to  develop  in  more  limited  and 
circumscribed  areas,  to  involve  a  greater  depth  of  the 
corium  and  the  subcutaneous  tissue,  and  to  be  accom- 
panied by  symptoms  of  malignancy.  The  area  of  each 
pustule  or  group  of  pustules  assumes  an  angry  look ; 
the  pus  formed  is  inspissated,  hemorrhagic,  and  com- 
mingled with  pultaceous  sloughs ;  the  resulting  crusts 
are  blackish,  the  scars  are  persistent,  and  the  pigmen- 
tation is  deforming  and  slow  to  disappear.  The  ulcers 
left  by  the  largest  and  most  formidable  of  these  lesions 
are  of  the  type  of  the  syphilitic  ulcer  in  general. 
They  have  clean-cut,  punched-out  edges,  a  floor  cov- 
ered with  an  adherent  pus-bathed  slough,  an  engorged 
base,  and  a  roof  at  times  constituted  of  the  successive 
desiccations  of  pus  formed  from  the  spreading  ulcer 
beneath,  so  that  a  stratified  conical  crust  with  limpet- 
shell  aspect  is  produced.  Here,  again,  the  circular, 
semicircular,  horseshoe-shaped,  and  other  combinations 
of  the  circle  so  oddly  characteristic  of  the  ulcers  of 
syphilis  are  constantly  encountered. 


Fig.  3. — Rupia  (after  Tilbury  Fox). 


The  oyster-shell-like  crusts  seen  in  various  sizes  in  so 
many  of  the  pustular  syphilodermata,  especially  over 
large-sized  lesions,  were  once  supposed  to  be  produced 


Plate  io. 


Pustulo-ulcerative  syphiloderm,  with  survival  of  sclerosis  of  the  penis. 


Plate  ii. 


Pustulo-ulcerative  syphiloderm  in  a  cachectic  subject. 


SYPHILIS   OF   THE   SKIN.  107 

in  other  diseases,  and  the  name  rupia  was  given  to  the 
malady  exhibiting  these  features.  One  of  the  axioms 
of  the  dermatology  of  to-day  is  that  the  symptoms  of 
rupia  are  those  of  syphilis.  Prior  to  the  formation  of 
these  crusts  there  is  always  a  history  of,  first,  infection ; 
second,  of  the  evolution  of  pustular  or  bullous  lesions 
with  hemorrhagic  or  semi-purulent  contents ;  third,  of 
the  bursting  of  the  chambers  containing  these  fluids ; 
fourth,  of  their  desiccation  into  greenish  or  greenish- 
black  crusts,  at  first  scarcely  larger  than  a  pea  or  a  bean, 
later  attaining  the  size  even  of  a  pullet's  egg ;  and,  lastly, 
of  a  series  of  elevations  of  the  stratified  and  conical 
crusts  by  successive  accumulations  from  a  constantly 
widening  area  beneath,  until  the  picture  of  the  rupioid 
skin  is  complete.  When  repair  ensues  the  crusts  fall, 
the  ulcers  granulate  and  become  simple  and  shallower, 
and  cicatrization  concludes  the  history.  Here,  as  so 
often  seen  in  other  of  the  syphilodermata,  the  under- 
lying ulcer  may  assume  any  of  the  circular  outlines  or 
the  shapes  of  imperfect  circles,  the  overspreading  rupioid 
crust  having  a  similar  configuration.  The  exanthem  is 
rarely  generalized,  though  in  extreme  cases  large  areas 
of  the  trunk  and  the  limbs  may  be  involved,  wide  spaces 
of  unaffected  skin,  however,  usually  intervening  between 
the  conspicuously  contrasting  crusts.  The  eruption 
occurs  most  frequently  in  the  cachectic,  the  weak,  and 
the  victims  of  malnutrition,  neglect,  and  poverty.  In 
every  instance,  however,  it  indicates  a  secondary  infec- 
tion with  cocci. 

The  other  pustulo-ulcerative  or  pustulo-crustaceous 
syphilodermata  are  variants  from  the  type  represented  in 
rupia,  and  most  commonly  in  the  direction  of  gravity- 
This  is  shown  by  such  results  as  an  increased  depth  of 
ulceration  and  more  profound  involvement  and  destruc- 
tion of  tissue.  Some  originate  as  single  or  multiple 
vesico-bullae  of  apparently  benign  character ;  some  as 
rapidly  degenerate  infiltrations  which  it  is  difficult  to 
distinguish  from    gummata.     All  are  apt  to   leave  in- 


I08      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

delible  cicatrices ;  yet,  even  after  multiple  ulcers  of 
severe  grade  have  riddled  the  integument  in  certain 
regions,  the  extent  to  which  repair  occurs  and  the  evi- 
dences of  damage  are  in  the  course  of  years  smoothed 
away  is,  as  a  rule,  surprising  to  those  not  familiar  with 
these  possibilities. 

In  some  cases  the  pustulo-crustaceous  syphilodermata 
imitate  the  tuberculo-ulcerative  lesions  of  syphilis  in  the 
formation  of  distinctly  circinate  and  serpiginous  groups 
of  pustules  surrounding  an  unaffected  centre,  or  one 
made  up  of  cicatricial  tissue  where  the  destructive 
process  has  yielded  to  repair.  In  many  of  these  in- 
stances the  original  pustulation  results  in  the  production 
of  an  annular  ulcer  covered  with  a  crust,  or,  in  parts  of 
the  circle,  in  the  production  of  a  firm  elevated  ring, 
often  later  breaking  down  by  softening  and  ulcerating. 
In  some  cases  the  process  is  more  deep  than  superficial ; 
there  is  an  angry,  dull-hued  areola  about  the  elevated 
and  crusted  ring ;  the  exposed  floor  of  the  ulcer  may  be 
papilliform,  smooth,  or  more  often  ill-conditioned  and 
covered  with  a  grayish  slough ;  and  in  its  path  destruc- 
tion of  deep  tissue  may  result,  such  as  the  loss  of  an  ala 
of  the  nose,  or  of  a  portion  of  the  lip,  or  of  an  ear.  In 
the  scalp  a  remediless  loss  of  hair  may  then  ensue. 

Diagnosis. — From  the  several  lesions  described  above, 
varicella  and  variola,  however  much  resemblance  may  be 
traced  between  the  former  and  either  of  the  latter,  may 
usually  be  distinguished  by  the  fever  of  invasion,  by  the 
relatively  active  rather  than  indolent  evolution  of  their 
lesions,  by  the  umbilication  of  the  fully-formed  variolous 
vesico-pustule,  and  by  the  multiplicity  of  lesions  in  severe 
variolous  cases,  in  which  the  lesions  usually  far  outnum- 
ber the  pustules  of  even  the  best-developed  syphiloderm 
of  the  same  type.  Signs  of  syphilis  other  than  pustular 
eruptions  may  be  recognized  in  most  patients  affected 
with  that  disease,  such  as  mucous  patches,  glandular 
involvement,  alopecia,  etc.  In  acne  the  usual  limitation 
of  the  eruption  to  the  regions  of  preference  of  that  dis- 


SYPHILIS   OF   THE   SKIN.  109 

ease  (face,  anterior  and  posterior  aspects  of  the  upper 
trunk)  is  generally  suggestive,  and  the  sprinkling  of 
comedones  among  the  pustules  is  significant.  In  syph- 
ilis, pustules  of  the  face  often  appear  in  conjunction  with 
similar  lesions  of  the  scalp ;  this  condition  is  practically 
never  seen  in  simple  acne,  the  scalp  in  the  latter  affec- 
tion being,  when  at  all  involved,  the  seat  of  either  a 
seborrhcea  or  an  alopecia  furfuracea.  Acne,  however,  is 
exceedingly  common  in  syphilitic  subjects,  and  it  should 
always  be  recognized  when  complicating  such  cases.  It 
occurs,  first,  as  a  result  of  ingested  medicines,  whether 
properly  or  improperly  administered  for  relief  of  the 
syphilis  present  (iodic  or  bromic  acne) ;  second,  as  the 
result  of  the  causes  efficient  in  the  production  of  acne 
in  the  non-infected  (alcoholism,  dyspepsia,  constipation, 
etc.).  Hundreds  of  patients  are  annually  treated  for  an 
ancient  syphilis  which  has  ceased  to  exhibit  evidences 
of  its  existence  and  yet  which  is  supposed  to  be  in 
activity  because  of  an  unsightly  acne. 

Pathology. — Under  the  microscope,  sections  of  a  pus- 
tular syphiloderm  resemble  very  greatly  those  made  in 
variolous  and  other  disorders  having  similar  lesions. 
The  usual  rents  in  the  epidermis  are  visible ;  its  remain- 
ing strata  are  pus-infiltrated ;  the  deeper  rete  is  eroded, 
in  parts  exposing  the  corium ;  the  individual  elements 
of  the  latter  are  filled  with  lymph-cells ;  the  blood- 
vessels are  distended,  and  in  places  are  choked.  Cham- 
bers originally  filled  with  pus  and  the  detritus  of  tissue 
are  readily  recognized  at  different  levels,  according  to 
the  depth  of  involvement  of  the  tissue.  Stretched  and 
torn  rete  and  corneous  cells  are  visible  both  in  the  cavi- 
ties and  in  the  walls  of  chambers  formed  by  the  exuded 
fluid.  At  times  the  site  of  the  pustule  is  a  hair- 
follicle,  in  which  case  its  adnexa  are  also  involved ;  at 
other  times  the  pus-making  process  attacks  the  corium 
outside  the  pilary  and  sebaceous  pouches.  Not  merely 
the  entire  corium,  but  the  subcutaneous  tissue  as  well, 
may  be  involved  (Cornil,  Kaposi). 


IIO      SYPHILIS  AiYD    THE  VENEREAL   DISEASES. 

IV.  Tubercular  Syphilodermata. 

Pathologically  there  is  little  difference  between  the 
tubercles  and  the  gummata  of  syphilis,  and  even  clin- 
ically the  distinction  between  the  two  cannot  always  be 
determined.  In  many  cases,  however,  it  is  a  matter  of 
convenience  to  distinguish  between  the  classical  forms 
of  these  frequent  lesions.  As  a  rule,  the  tubercle  is 
more  superficial  than  the  gumma,  occurs  in  less  grave 
forms  of  the  disease,  is  more  apt  to  resolve  and  less  dis- 
posed to  degenerate,  develops  at  an  earlier  period,  is 
much  more  often  multiple  and  exceedingly  numerous, 
and  occurs  in  a  larger  number  of  patients  in  forms  that 
are  grouped. 

Syphilitic  tubercles  may  develop  in  the  course  of  a 
few  months  after  infection,  but  they  are  more  common 
after  the  lapse  of  from  two  to  ten  years.  They  invade 
the  face  and  the  extremities,  and  in  these  situations  and 
elsewhere  (for  they  may  be  found  in  any  region  of  the 
body)  are  pea-,  split-pea-  to  bean-sized  lesions,  the 
smaller  dimensions  named  being  most  frequently  at- 
tained. They  are  firm,  well-defined  nodules,  neither 
definitely  flattened  nor  acuminate  at  the  surface,  with  a 
tendency  to  assume  the  globoid  shape.  In  color  they  are 
reddish-brown  or  copper-tinted,  the  hue  deepening  to  a 
dark  empurpled  shade  in  the  extremities  by  reason  of 
gravity,  and  in  the  face  after  great  congestion  or 
unusual  exertion,  such  as  dancing.  Their  grouping  is 
distinctively  and  characteristically  in  circles  and  por- 
tions of  circles,  further  extension  of  the  eruption  being 
by  the  formation  of  new  and  adjacent  rings  producing 
the  figure  8,  the  letter  S,  the  dumb-bell,  and  the  "  satel- 
lites," as  in  the  arrangement  of  a  jeweller's  brooch.  As 
they  differ  in  respect  to  the  mode  of  their  involution, 
they  furnish  thus  a  basis  for  a  useful  distinction. 

Resolutive  (''•Dry,"  "Non-ulcerative,"  "Atrophic") 
Tubercular  Syphiloderm.  —  In  this  class  are  placed 
tubercular  lesions  which  degenerate  not  by  ulceration, 


SYPHILIS   OF   THE   SKIN. 


Ill 


but  by  resolution  through  metamorphosis  of  the  effused 
product  beneath  an  unbroken  epidermis.  The  result  is 
unique — namely,  the  formation  of  a  cicatrix  where  there 
has  been  no  loss  of  continuity  in  the  outer  layer  of  the  skin. 
The  tubercles  are  then  effaced  by  a  species  of  atrophic 


Fig.  4. — Resolutive  tubercular  syphiloderm  in  groups. 

change,  leaving  a  pigmented  and  cicatricial  macule  in 
the  site  of  each  tubercle,  the  pigment  at  a  later  date 
fading  and  leaving  in  its  site  conspicuous  indented  scars 
somewhat  smaller  than  the  original  tubercle.  These 
groups  of  scars,  circumscribed  and  with  their  pigment 
but  partially  removed,  forming  portions  of  an  imperfect 
circle,  one  arc  of  which  is  represented  by  tubercles  as 
yet  unresolved  or  but  partially  effaced,  is  one  of  the 
most  striking  of  the  pictures  presented  in  syphilis,  and 
one  not  imitated  in  any  other  disease.  Upon  the  face 
(Fig.  4),  about  the  knee,  upon  the  elbow,  or  over  the 
anterior  aspect  of  the  forearm  in  its  lower  third,  these 
striking  composite  groups  are  always  significant  to  the 
trained  eye.  Tubercles  of  this  class  upon  the  palms  and 
the  soles  are  exceedingly  apt  to  scale  in  process  of  either 
evolution  or  involution,  the  scaling  being  at  both  the 
summits  and  the  sides  of  the   lesions.     The   tubercles 


112      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

are  in  no  way  distinguishable  from  those  described  be- 
low, save  in  the  matter  of  their  historical  career. 

The  tubercles  may  be  grouped  or  generalized,  and  are 
few  or  exceedingly  numerous.  They  may  develop  be- 
tween the  second  and  the  fifth  or  sixth  year  after  infec- 
tion, though  they  may  be  observed  at  a  much  later  date. 
They  begin  as  subcutaneous  circumscribed  infiltrations, 
having  a  dull-reddish  or  ham-colored  hue,  and  vary  in 
size  from  that  of  a  split  pea  to  that  of  a  small  nut. 
They  are  commonly  roundish  in  outline,  smooth  ex- 
ternally, and  not  productive  of  subjective  sensation.  In- 
deed, a  characteristic  feature  of  an  ancient  group  of 
syphilitic  tubercles  is  the  remarkable  toleration  with 
which  the  subject  of  the  disease  has  for  so  long  a  time 
sustained  its  encroachments.  Regions  of  special  prefer- 
ence for  this  exanthem,  when  occurring  in  isolated 
groups,  are  the  forehead,  the  front  and  back  of  the 
neck,  the  outer  aspect  of  the  elbow,  the  knee  below  the 
patella,  and  the  sacral  and  suprascapular  regions.  It  is 
clear  from  a  study  of  these  regions  that  the  tubercular 
syphiloderm  is  one  frequently  excited  to  activity  and 
prolonged  in  career  by  exposure  of  the  body  to  friction 
and  other  sources  of  irritation.  The  truly  gigantic  areas 
of  involvement,  illustrated  in  some  of  the  published 
plates,  are  usually  found  on  the  backs  of  day  laborers, 
whose  flannel  shirts,* saturated  with  sweat,  are  potent 
sources  of  mischief. 

Striking  as  are  the  annular  figures  of  this  eruption 
with  healed  or  unaffected  areas  in  the  enclosure  of  the 
ring,  the  vegetating  forms  are  even  more  conspicuous. 
In  the  regions  named  above,  but  also  over  the  scalp, 
especially  of  relatively  young  women,  extensive  verru- 
cous growths,  capped  with  characteristic  warty  tufts, 
ridges,  or  even  papillomatous  masses  ("  la  syphilide  papil- 
lojnateiise"),  develop  on  the  sites  of  involvement,  the 
matted  hairs  smeared  with  a  foul-smelling  secretion, 
producing  a  highly  repulsive  group  of  symptoms.  In 
yet  other  instances  the  tubercular  lesions  are  agglutinated 


SYPHILIS    OF   THE   SKIN.  II3 

in  a  dense,  yellowish,  coriaceous  mass ;  and  in  others, 
again,  the  well-defined  area  of  infiltration  furnishes  a 
field  where  it  is  difficult  to  recognize  the  original  ele- 
ments of  the  eruption,  especially  when  long  subjected  to 
the  friction-effects  described  above.  In  these  large 
patches  the  thickened  integument,  with  raised  and  well- 
defined  border,  comes  to  resemble  the  bark  of  a  tree,  its 
dense  scales  here  and  there  massed  about  points  of 
special  infiltration,  and  here  and  there  studded  with 
pustules  where  pyogenic  infection  has  attacked  the  in- 
volved area.  In  cases  these  large  fields  of  invasion  have 
been  practically  unchanged  for  months  or  years ;  in 
other  cases,  especially  after  efficient  treatment,  one  can 
recognize  smoother,  deeply  pigmented  patches,  with 
occasionally  interspersed  superficial  cicatrices  where  the 
infiltration  has  been  deepest,  longest  neglected,  and  suc- 
ceeded by  effective  absorption  of  the  effused  morbid 
material. 

Ulcerative  Tubercular  Syphiloderm. — In  this  arti- 
ficial class  the  tubercles  degenerate  by  ulceration,  this 
change  occurring  in  different  cases  as  a  modification 
either  of  the  elementary  lesion  itself  or  of  the  underly- 
ing tissues  to  which  the  ulcer,  originally  limited  to  the 
tubercular  mass,  eventually  extends.  In  the  simplest 
form  these  tubercles  soften  at  the  summit,  exhibiting  at 
this  point  a  more  or  less  adherent,  slightly  sloughy 
crust.  If  this  crust  be  removed  with  more  or  less  force 
at  an  early  period,  it  can  readily  be  seen  that  an  ulcera- 
tive process  has  begun  to  destroy  the  upper  portion  of 
the  small  tumor.  All  the  stages  of  ulceration  and  repair 
that  follow  depend  upon  the  general  condition  of  the 
patient  and  the  good  or  bad  treatment  and  hygienic  aid 
which  he  receives.  When  the  ulcer  spreads  beyond  the 
mass  of  the  elementary  tubercle,  it  passes  into  the  cate- 
gory of  gummatous  lesions ;  but  if  the  degeneration 
is  limited  to  the  original  tubercle,  the  clinical  picture  is 
distinct.  In  these  cases  circlets,  complete  or  partial,  of 
crusted  tubercles  or  of  crust-covered  and  circumscribed 


114      SYPHILIS  AND    THE  VENEREAL    DISEASES. 

ulcers  surround  an  unaffected  or  infiltrated  area  of  skin, 
the  color  of  which  is  of  the  type  seen  in  the  resolutive 
groups  described  above.  Upon  the  face,  where  these 
lesions  are  of  special  importance  and  of  frequent  occur- 
rence because  of  the  exposure  of  this  region  of  the 
body  to  frictional,  accidental,  and  atmospheric  influences, 
the  arrangement  may  be  less  distinctively  in  circles ; 
as,  for  example,  over  the  sides  of  the  nose,  where  crusted 
nodules  may  be  indiscriminately  sprinkled  over  one  or 
both  sides  with  as  little  order  as  the  lesions  of  acne 
with  which  this  syphiloderm  has  at  times  been  confused. 


Fig.  5. — Serpiginous  tubercular  syphiloderm  (after  Stelwagon). 

Upon  the  trunk  and  the  limbs,  however,  the  tubercles 
are  often  not  merely  grouped  originally  in  circles  or 
parts  of  circles,  but  they  spread  at  times  by  serpiginous 
extension  until  wide  areas  have  been  swept  over  (Fig. 
5),  leaving,  where  the  activity  of  the  process  was  once 
declared,  broad,  palm-sized  and  even  much  larger  cicatri- 
cial patches  where  the  skin  is  thinned,  and  where  one  can 
recognize  the  pea-sized  and  smaller,  depressed  and  cir- 
cumscribed points,  each  representing  the  site  of  a  former 
tubercle  and  ulcer.     Often  giant  circles  of  involvement, 


SYPHILIS  OF   THE   SKIN.  1 1  5 

affecting,  for  example,  an  entire  buttock  or  a  portion  of 
the  back,  have  in  this  way  indolently  progressed  for 
years,  the  nature  of  the  disorder  being  misunderstood 
for  that  period.  Many  patients  thus  afflicted  have  been 
treated  for  years  for  "  lupus,"  "  tuberculosis,"  and  other 
affections,  relief  having  speedily  been  effected  after  dis- 
covery of  the  exact  nature  of  the  malady. 

When  tubercles  of  this  class  coalesce  and  degenerate, 
it  is  at  times  difficult  to  recognize  the  elementary  lesion 
present.  In  these  cases,  obscure  only  to  the  inexpert, 
the  encircling  series  of  small  tubercles  is  replaced  by  a 
rim-like  wall  of  elevated  tissue,  either  broken  down  at 
several  points  by  the  ulcerative  process  or  preparing  to 
break  down.  The  area  enclosed  may  also  be  found  to 
consist  of  an  infiltrated  disk  with  circles  or  segments  of 
circles  within  the  parent  group,  some  ulcerating  at  the 
outer  border,  others  wholly  or  partially  cicatrized  in 
ineffectual  attempts  to  insure  repair.  Typical  tuber- 
culo-ulcerative  patches  strongly  resemble  many  of  the 
ulcerations  following  degeneration  of  gummata,  and 
it  is  to  be  remembered  that  the  process  in  each  is 
essentially  the  same,  the  differences  being  due  solely 
to  artificial  classification.  In  all  the  grave  and  widely- 
diffused  ulcerations  springing  from  syphilitic  tubercles, 
as  a  rule,  the  elements  last  named  soon  become  incon- 
spicuous features  of  the  general  process.  Repair  of  the 
degenerative  losses  here  described  occurs  by  granula- 
tion of  the  ulcers,  by  effacement  and  resolution  of  those 
not  yet  having  undergone  degeneration,  and  by  the 
eventual  production  of  multiple  cicatrices,  which,  being 
often  arranged  in  groups  of  circles  adjacent  to  or  encom- 
passed by  others,  furnish  unmistakable  evidence,  years 
after  the  date  of  the  development  of  the  tubercles,  of  a 
syphilitic  infection  in  the  past. 

Diagnosis. — The  diagnosis  of  a  tubercular  syphilo- 
derm,  present  or  past,  is  of  the  very  highest  importance 
for  the  diagnostician,  seeing  that  years  may  have  elapsed 
after  the  date  of  infection  before  attention  is  attracted  to 


Il6      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

the  eruptive  symptoms.  Upon  the  diagnosis  may  rest 
a  question  of  life  or  death,  as,  for  example,  when  a  man 
lies  unconscious  from  a  gummatous  involvement  of  a 
portion  of  the  meninges  of  the  brain,  and  there  is  only 
a  tell-tale  scar  on  the  buttock  or  the  loin  to  indicate  the 
original  nature  of  his  disorder. 

The  papular  and  tubercular  forms  of  acne,  especially 
in  florid-faced  male  subjects  of  alcoholism,  occasionally 
resemble  a  tubercular  syphiloderm  of  the  nasal  region ; 
but  in  syphilis  there  is  usually  complete  failure  of 
symmetry,  one  side  of  the  nose  being  predominantly 
involved,  though  the  exceptions  are  not  rare.  In  acne 
the  evident  involvement  of  the  sebaceous  glands,  the 
tortuous  vessels  visible  about  the  lesions,  and  the  general 
rosaceous  appearance  of  the  organ  are  characteristic. 
In  syphilis,  when  at  all  advanced,  there  is  either  distinct 
crusting  or  superficial  ulceration  beneath  the  crusts, 
either  of  which  signs  suffices  to  distinguish  the  nature 
of  the  disease. 

The  several  forms  of  eczema  are  all  recognized  by 
their  inflammatory  aspect,  their  catarrhal  features,  the 
intense  pruritus  they  awaken,  and  the  general  absence 
of  distinct  contour.  The  scales  and  the  absence  of 
scarring  and  ulceration  in  psoriasis  usually  suffice  for 
its  determination.  Lupus  vulgaris,  one  of  the  forms 
of  cutaneous  tuberculosis,  is  perhaps  more  often  con- 
founded with  syphilis,  or  the  latter  with  the  former, 
than  are  any  confused  diseases.  The  distinction  is  al- 
ways a  matter  of  great  importance.  It  must  be  borne 
in  mind,  when  confronted  with  any  doubtful  case,  first, 
that  lupus  vulgaris  is  a  disease  most  often  beginning  in 
the  first  or  the  early  part  of  the  second  decade  of  life, 
syphilis  usually  dating  either  from  the  latter  part  of  the 
second  decade  or  from  that  which  follows  it;  second, 
that  lupus  vulgaris  is  decidedly  less  common  than  tuber- 
cular syphilis  ;  third,  that  the  latter  is  usually  presented, 
in  any  doubtful  case,  at  a  period  from  three  to  eight  or 
more  years  after  the  date  of  infection ;    lastly,  that,  as 


SYPHILIS   OF   THE   SKIN.  WJ 

regards  chronicity,  syphilis  is  a  relatively  rapid  disease, 
producing  in  six  months  or  less  a  destructive  result  which 
tuberculosis  would  require  as  many  years  to  accomplish. 

The  nodules  of  lupus  are  readily  perforated  with  a 
blunt-pointed  needle ;  those  of  syphilis  resist  a  firm 
impression.  In  lupus,  even  though  a  patch  be  formed, 
it  distinctly  lacks  the  ovoid  or  truly  circular  configura- 
tion assumed  by  groups  of  syphilitic  tubercles,  and  it 
may  be  said  never  to  produce  the  combinations  of  circles 
previously  described.  The  same  is  true  of  the  ulcers  of 
lupus  as  distinguished  from  those  of  syphilis,  the  floors 
of  syphilitic  ulcers,  further,  being  generally  covered  with 
a  pultaceous  slough  surrounded  by  steep-walled  edges, 
while  the  edges  of  the  lupous  ulcer  are  thin  and  stretch 
over  softish,  pulpy,  jelly-like  masses  of  indolent  granu- 
lations. The  degree  of  pain  experienced  is  far  greater 
in  syphilis  than  in  lupus.  Over  the  face,  lupus,  whether 
destroying  by  absorption  of  the  effused  product  or  by 
ulceration,  produces  the  characteristic  "  parrot's-beak  " 
deformity  of  the  nose  or  reduces  it  or  the  ear  to  a 
shrunken  miniature  of  its  former  self;  while  syphilis 
boldly  destroys  one  ala  and  at  the  same  time  spreads  in 
the  nasal  fossae,  attacking  the  bones  of  the  nose  and  pro- 
ducing its  special  deformity  by  the  sinking  of  the  bridge. 
In  tubercular  syphilis  of  the  face  a  circlet  of  lesions 
forming  an  infiltrated  disk  consisting  of  partly  flattened 
and  partly  ulcerated  tubercles  is  apt  to  attack  one  side 
of  the  brow  near  the  root  of  the  nose  or  to  encircle  one 
angle  of  the  mouth ;  while  a  lupous  patch  will  involve 
rather  the  centre  of  one  or  of  both  cheeks,  and  will  dis- 
play as  many  of  its  uniformly  reddish-brown  nodules 
in  the  enclosure  as  at  the  periphery  of  the  patch. 

Epitheliomatous  ulcers,  of  the  face  especially,  are  more 
readily  distinguished  from  those  of  syphilis.  They  are 
often  surrounded  by  characteristic  "pearls"  of  cancerous 
growth ;  they  occur  in  a  much  older  class  of  sub- 
jects ;  their  floors  are  smooth  and  glazed,  rarely  sloughy; 
their  edges  are  strongly  everted ;  they  are,  as  a  rule,  by 


Il8      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

no  means  painful ;  and  they  observe  a  far  slower  evolu- 
tion, lasting  for  years  without  apparent  change. 

It  is  to  be  remembered  also  that  in  all  forms  of  sycosis 
the  hair-follicles  are  primarily  involved,  and  the  disease 
is  strictly  limited  to  the  region  of  the  male  beard ;  that 
in  leprosy  the  nodules  of  the  face  producing  the  leonine 
aspect  are  never  arranged  in  circles,  but  in  ridges  and 
rows  along  the  brows,  and  have  a  characteristically  var- 
nished appearance;  that  in  rhinoscleroma  —  a  disease 
reported  in  but  a  few  isolated  cases  in  America — there 
is  a  firm,  ivory-like  hardness  to  the  portions  of  the  nose 
involved  that  is  not  characteristic  of  syphilis ;  and  that 
in  zoster  of  the  face  it  is  rare  indeed  that  both  sides  are 
involved,  there  being  usually  a  strict  limitation  to  one 
side  of  the  face  of  firm  nodules  just  ready  to  develop 
into  vesicles. 

V.  Gummatous  Syphiloderm. 
Gummata  of  the  skin  are  circumscribed  firm  nodules, 
usually  involving  either  the  subcutaneous   or  the  sub- 
mucous tissue,  and  often  attacking  later  the  underlying 


Fig.  6. — Gummata  (after  Jullien 


structures,  such  as  fascia,  periosteum,  bone,  cartilage, 
and  tendon.  They  vary  in  size  from  that  of  a  small  nut 
to  that  of  an   orange,  and  they  are   at   first   uncolored 


Plate  12. 


Tuberculo-gummatous  infiltration  of  the  skin  with  ulceration  (Mracek). 


Lith.  Anst  E  ReichholcL  Munci 


SYPHILIS   OF  THE   SKIN.  II9 

elevations  of  the  skin,  but  later,  when  degeneration  is 
threatened,  the  integument  over  each  nodule  becomes 
purplish,  livid,  boggy,  and  thinned  to  a  point  where 
bursting  of  the  contents  of  the  gumma  occurs  through 
its  connective-tissue  envelope.  Its  name  is  derived  from 
the  gummy  character  of  the  product  evacuated  when 
bursting  of  the  neoplasm  ensues.  When  freely  forming 
upon  a  level  surface,  gummata  are  usually  globoid  in 
contour,  but  they  may  be  instead  irregularly  shaped 
and  even  flattened.  They  are  rarely  very  numerous  in 
one  subject  at  a  given  time,  many  patients  never  exhibit- 
ing more  than  one,  or  at  the  most  two  or  three,  typical 
gummata  (Fig.  6) ;  in  rare  instances  hundreds  form  at 
one  time  in  the  same  person. 

Gummata  are  usually  counted  as  "  late "  syphilitic 
lesions,  but  they  may  develop  within  a  few  months  after 
infection.  As  a  rule,  however,  from  two  to  five  years  or 
more  elapse  between  the  date  of  the  appearance  of  the 
chancre  and  their  evolution.  They  may  be  the  final 
evidences  of  the  syphilitic  process,  or  they  may  again 
and  again  return  in  the  neighborhood  of  the  first  site  of 
their  appearance,  until  the  skin  and  the  underlying 
tissues  are  seamed  with  scars  commingled  with  healing 
and  unhealed  nodules,  and  connected  by  bridges  of  ap- 
parently sound  skin  beneath  which  run  sinuous  channels 
of  ulceration. 

At  times  the  gummatous  product  is  more  or  less 
widely  diffused  in  a  particular  region  of  the  body,  such 
as  the  leg  or  the  shoulder ;  in  these  cases,  especially  if 
the  disease  has  existed  for  some  time,  the  appearance  is, 
however  characteristic  of  late  syphilis,  not  always  sug- 
gestive to  the  eye  of  its  real  character.  In  these  in- 
stances large  areas  as  broad  as  the  hand,  often  with 
tolerably  distinct  demarcation,  present  an  exceedingly 
irregular  and  confused  surface,  seamed  with  ridges,  over- 
sprinkled  with  nodules  and  dense  indurations,  and  per- 
forated here  and  there  with  ulcers.  In  extreme  cases, 
where  the  nature   of  the  disease  has  been  wholly  un- 


120      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

recognized  for  years  and  where  intercurrent  eczematous 
and  other  affections  have  complicated  the  process,  a 
singular  variation  of  type  occurs  ;  and,  especially  where 
gravity  has  added  its  influence,  as  in  the  leg,  there  may 
be  an  elephantiasic  result  which  requires  careful  scru- 
tiny for  an  accurate  diagnosis.  In  these  severe  cases 
the  nature  of  the  disease  can  generally  be  recognized 
after  study  of  a  small  portion  of  the  invaded  area, 
where,  wellnigh  hidden  in  a  mass  of  tumefaction,  a  tell- 
tale scar  or  a  circular  ulcer  with  typical  edge  and  floor 
reveals  the  truth.  In  another  extreme  type  the  entire 
gummatous  tissue  breaks  down  into  a  gigantic  ulcer  as 
large  as  or  larger  than  a  platter,  with  an  indolent  and 
sloughy  floor,  a  circular  outline,  and  an  engorged  base. 
As  a  consequence  of  the  force  of  gravity,  it  is  most 
common  to  discover  these  ulcerations  on  the  leg,  but 
they  are  seen  also  on  the  shoulders  and  on  the  back. 
When  in  the  former  situation,  however  extensive,  they 
rarely  completely  girdle  the  ankle  or  the  lower  third  of 
the  leg,  as  may  other  ulcerative  processes  in  this  region, 
but  a  considerable  portion  of  the  skin,  usually  posterior 
in  position,  remains  unaffected.  Upon  the  face  the 
destruction,  if  less  extensive,  is  usually  more  hideous 
(Fig.  7).  Here  a  gigantic  excavation  may  result  from 
the  breaking  down  of  gummatous  infiltrations  whereby 
the  nasal  and  oral  cavities  are  converted  into  one  gaping 
chasm,  as  in  the  severe  grades  of  epithelioma.  A  large 
portion  of  the  pinna  of  one  ear  may  slough.  The  bones 
of  the  face,  skull,  and  jaws  frequently  suffer,  and  ectro- 
pion, flattening  of  the  nasal  bridge,  and  extensive  mutila- 
tion of  the  lips  and  the  ears  may  ensue. 

Not  the  least  conspicuous  among  the  distinctive  feat- 
ures of  these  severe  ravages  of  syphilis  is  the  extraordi- 
nary extent  to  which,  when  properly  treated,  repair 
ensues.  When  the  general  cachectic  condition  (evident 
in  almost  all  this  class  of  patients)  yields  to  proper  hy- 
gienic and  medicinal  treatment,  cicatrization  follows  after 


SYPHILIS   OF   THE   SKIN.  121 

even  the  most  extensive  and  mutilating  damage ;  the 
deformity  is  slowly  smoothed  away  so  as  to  escape  rec- 
ognition save  by  the  experienced  eye,  and  the  patient 
may  enjoy  a  future  life  without  return  of  the  old  trouble. 
In  this  way  an  obturator  enables  one  man  to  close  the 


Fig.  7. — Cicatrices  resulting  from  extensive  gummatous  infiltration  of  the  face. 

gap  between  the  mouth  and  the  nasal  cavity ;  another, 
who  has  an  opening  connecting  the  oesophagus  and  the 
larynx,  can  in  certain  postures  and  by  the  aid  of  special 
devices  swallow  food  without  its  access  to  the  respiratory 
tract ;  and  even  the  most  disfiguring  scars  of  the  face  are 


122      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

slowly  freed  from  pigment  and  diminished  in  circum- 
ference and  irregularity  until  a  degree  of  sightliness  is 
produced  (Fig.  f).  It  should  not  be  forgotten,  espe- 
cially in  relatively  young  patients,  that  even  with  the 
worst  accidents  the  recovery,  under  anything  like  fair 
treatment,  will  surpass  the  hopes  of  the  most  sanguine. 
It  is  in  this  respect  that  syphilis  draws  a  sharp  and 
significant  distinction  between  itself  and  all  other  dis- 
eases productive  of  destructive  effects — a  distinction  of 
the  highest  value  with  respect  to  diagnosis. 

Diagnosis. — The  term  "gumma"  has  lately  been 
affixed  to  the  somewhat  similar  cutaneous  lesions  of 
tuberculosis  (lupoma,  gomme  scvofiilense),  and  the  resem- 
blance between  these  and  the  gummata  of  syphilis  is  not 
slight.  In  the  former  the  recognition  of  other  tuber- 
culous or  scrofulous  symptoms,  their  occurrence  at  an 
earlier  period  of  life  than  most  cases  of  syphilis,  and  the 
characteristic  elevated  longitudinal  ribbons  of  empurpled 
and  thinned  skin,  especially  on  the  neck,  enclosing  depots 
of  ill-conditioned  pus,  are  common.  When  degenerat- 
ing, there  are  formed  linear  or  narrow  ulcers  with 
thinned  edges  and  pulpy  floors  covered  with  soft  granu- 
lations, the  enlarged  glands  in  the  vicinity  not  yet  being 
broken  down. 

Sarcomatous  tumors  are  usually  multiple,  occur  in 
conditions  where  cachexia  is  more  marked,  and  are,  as  a 
rule,  slower  of  evolution  than  syphilitic  gummata, 
though  at  times  undergoing  rapid  changes.  They  are 
rarer  in  the  lower  extremities  than  elsewhere — a  dis- 
tinguishing feature  of  gummata  in  syphilis. 

Lipomata  are  readily  differentiated  from  gummata  by 
the  softness  to  the  touch  of  the  former  and  by  the 
"pillowy"  feel  of  the  growths,  which,  furthermore,  are 
usually  of  far  longer  duration  without  change  than 
syphilitic  tumors.  From  a  gumma,  epithelioma  is  at 
times  distinguished  with  ease,  at  others  with  very  great 
difficulty.       The    following  points    are    to    be    remem- 


Plate  14. 


Gummatous  involvement  of  the  cervical  glands  (Mracek). 


Lith.Anst  F.  ReLchJwld,  Munch 


SYPHILIS   OF   THE   SKIN.  1 23 

bered :  Cancer,  as  a  rule,  occurs  at  a  later  period  of  life, 
but  at  times  the  gummatous  changes  in  syphilis  occur 
at  the  same  age.  In  epithelioma  of  the  skin  the 
"pearls"  or  waxy  nodules,  scarcely  larger  than  pin- 
heads  of  good  size,  are  characteristic,  and  are  never  seen 
in  syphilis.  The  course  of  an  epithelioma  of  the  skin 
is  far  slower  than  the  career  of  a  gumma,  the  latter 
rarely  requiring  more  than  a  few  months  for  its  termina- 
tion either  by  resolution  or  by  disintegration,  while  a 
cancer  of  the  skin  may  endure  with  less  destruction  for 
a  decade  of  years.  Multiplicity  is  true  of  the  syphilitic 
more  often  than  of  the  cancerous  ulcer.  The  edges  of 
the  specific  ulcer  are  steep  or  undermined ;  those  of  the 
epitheliomatous  excavation  are  everted  often  to  a  very 
marked  degree.  In  syphilitic  ulcer  the  floor  is  sloughy 
or  pus-bathed ;  in  cancer  it  is,  when  typical,  covered 
with  a  thin,  varnish-like  secretion  which  scarcely  conceals 
the  florid  and  irregularly  excavated  surface  beneath. 

Gummata  of  the  progenital  region  are  at  times  liable 
to  be  confounded  with  initial  scleroses  and  chancroids, 
but  the  accompanying  adenopathy  of  the  latter,  their 
relatively  rapid  career,  and  the  greater  extent  of  the 
infiltration  of  the  gumma  usually  indicate  the  difference. 
The  chancroid  is  always  more  distinctly  purulent  and 
less  indurated  than  the  gumma. 

Ulcers  of  the  leg  resulting  from  pressure-effects  in 
the  subjects  of  varicose  veins  of  this  region  and  of 
the  thigh  often  present  a  strong  resemblance  to  the 
ulcers  of  syphilis,  but  the  distinction  between  the  two 
can  usually  be  made  without  difficulty.  In  the  one  case 
the  enlarged  veins,  in  the  other  the  painful  character  of 
the  trouble,  the  cedematous  condition  of  the  limb,  the 
frequent  coexistence  of  eczema,  and  the  entire  absence 
of  a  well-rounded  scar  or  a  deep  circular  ulcer,  usually 
aid  in  the  diagnosis.  The  picture  in  the  non-specific 
disease  is  usually  more  serious  than  in  the  syphilitic 
disorder  which  it  is  sought  to  differentiate.     The  pig- 


124      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

mentation  in  long-standing  cases  is  far  deeper  and 
blacker  in  shade  in  the  varicose  condition,  in  conse- 
quence of  the  extravasation  of  blood.  A  tolerably  clear 
outline  to  any  given  patch  of  diseased  skin,  and  an 
absolutely  unaffected  integument  in  close  proximity  to 
an  ulcerated  or  engorged  patch,  point  always  in  the 
direction  of  syphilis. 

Pathology. — Anatomically,  the  tubercle  and  the 
gumma  of  syphilis  are  practically  identical.  The 
process  is  essentially  one  of  disintegration  of  the  com- 
ponent parts  of  the  nodule,  with  central  fatty  and  puru- 
lent degeneration  of  fibres,  cells,  and  nuclei,  and  pe- 
ripheral proliferation  with  round  cells  commingled  with 
few  giant-cells  surrounded  by  connective-tissue  fibres. 
The  zone  of  proliferation  about  the  central  depot  of 
globules  is  evidently  protective  in  character  (Kaposi, 
Basset). 

The  groups  of  syphilodermata  described  above  are 
classified  in  the  artificial  divisions,  between  which  they 
can,  for  the  most  part,  readily  be  separated.  There  are, 
however,  a  few  manifestations  of  syphilis  in  the  skin, 
the  peculiar  features  of  which  justify  special  considera- 
tion. They  are,  in  point  of  fact,  modifications  of  the 
symptoms  already  described. 

Serpiginous  Syphiloderm. — The  term  "serpiginous" 
was  originally  employed,  as  its  etymology  suggests, 
to  designate  a  lesion  displaying  "  creeping "  features, 
a  slow  and  gradual  extension  from  one  point  or  from 
several  points  to  others  on  the  cutaneous  surface.  At 
present  the  word  designates  the  peculiarities  which 
may  be  assumed  by  one  or  another  of  the  syphiloder- 
mata, rather  than  any  special  exanthem  of  syphilis. 
In  a  serpiginous  eruption  there  is  extension  of  the  dis- 
ease, either  by  ulceration  or  by  retrograde  metamor- 
phosis, at  the  periphery  of  an  involved  patch,  while  the 
central  portion  is  the  seat  of  partial  or  complete  cicatri- 
zation.    While  this  effect  may  not  rarely  be  noticed  in 


SYPHILIS   OF  THE   SKIN.  12$ 

any  of  the  ulcerating  or  resolving  syphilodermata  in 
groups,  the  term  "serpiginous"  is  applied  specifically 
to  those  cases  in  which  this  peripheral  extension  and 
centric  involution  are  decidedly  more  pronounced  than 
other  features  of  the  disease  at  any  time  present. 

The  serpiginous  feature  may  be  assumed,  as  has  been 
seen,  by  a  group  either  of  pustules,  tubercles,  papules,  or 
gummata.  Beginning  with  one  or  a  group  of  several  of 
such  lesions,  the  process  may  be  either  superficial  or 
deep.  As  a  rule,  the  most  ambulant  and  erratic  of  these 
serpiginous  patches  belong  to  the  former  rather  than  to 
the  latter  class. 

On  the  earliest  recognition  of  a  serpiginous  tendency 
in  any  patch  of  disease,  it  can  be  seen  that  the  clearly- 
defined  peripheral  wall  is  spreading  either  in  equal  radia- 
tions from  a  central  point  (artificially  placed)  or,  rather 
more  commonly,  more  actively  in  one  direction  than  in 
any  other.  The  peripheral  wall  may  be  built  up  either 
of  confluent  papules  or  tubercles  or  any  crusted  lesions 
of  the  types  named,  or  by  sequelae  of  any  of  the  latter 
in  the  form  of  a  shallow  ulcer,  circular  in  outline,  re- 
sembling a  moat  about  an  enclosed  field.  The  central 
area  may  then  be  made  up  of  infiltrated  integument, 
pigmented  or  otherwise  discolored,  or  by  small  coin- 
sized  cicatrices,  or  by  partly-healed  ulcers  of  smaller 
dimensions  than  the  mother-lesion  within  which  they 
are  confined.  As  the  environing  circle  with  its  wall  and 
open  or  crusted  ulcer  widens,  the  central  area  proceeds 
to  a  more  complete  involution,  leaving  at  last  broad 
spaces  often  converted  into  a  smooth  scar-tissue,  or  a 
field  in  which  the  delicate  creases  and  punctate  markings 
suggest  the  action  of  the  tool  of  the  engraver  on  the 
surface.  This  odd-looking  involvement  of  the  integu- 
ment may  be  in  progress  for  months  and  years,  spread- 
ing from  one  or  more  primary  points  and  gradually 
migrating  over  an  entire  thigh  or  abdomen,  the  patient 
meantime  often  displaying  in  other  respects  a  marked 
degree  of  general  health  and  vigor. 


126      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

When  the  action  is  deeper,  the  ulceration,  invading  the 
subcutaneous  and  even  the  deeper  structures,  usually 
begins  with  the  disintegration  of  tubercle  or  gumma  and 
spreads  by  extension,  more  often  downward  and  deeply 
rather  than  peripherally  and  at  the  superficies.  In  this 
way  there  are  digged  in  the  muscles,  the  fascia,  and 
between  the  tendons,  gigantic  excavations  each  having 
usually  the  circular  outline  and  the  sloughy  floor  of  the 
syphilitic  ulcer,  and  exhibiting  a  marked  tendency 
toward  phagedena.  Both  superficial  and  deep  forms 
of  serpiginous  ulceration  occur  for  the  most  part  in 
persons  of  a  broken-down  constitution  ;  they  are,  how- 
ever, encountered  among  the  fleshy,  the  consumers  of 
alcohol  in  excess,  and  those  given  to  modes  of  life  which 
in  non-syphilitic  subjects  are  specially  favorable  to  the 
production  of  gout.  They  are  exceedingly  rare  in 
young  and  sturdy  subjects   of  the  disease. 

Diagnosis. — The  disease  most  likely  to  be  con- 
founded with  serpiginous  forms  of  syphilis  of  the  skin 
is  a  variety  of  chancroid  to  which,  at  times,  the  title 
"  serpiginous  chancroid "  has  been  applied.  In  the 
latter  affection  the  ulceration  is  most  often  subcutaneous 
in  situation,  spreading  for  years,  at  times  insidiously, 
beneath  bridles  and  bridges  of  apparently  unaltered  skin, 
often  with  enlarged  glands  in  the  vicinity,  generally 
upward  over  the  belly  or  downward  over  the  inside  of 
the  thigh,  almost  never  elsewhere.  The  history  usually 
gives  some  clue  to  the  solution  of  the  problem. 

The  vegetating  forms  of  epithelioma  are  often  exceed- 
ingly like  the  serpiginous  syphiloderm,  extending  from 
a  central  area  in  verrucous  growths  at  the  periphery  of 
a  patch  which  has  at  times  a  well-rounded  outline.  In 
this  event  the  advanced  age  of  the  patient,  the  absence 
of  enclosed  minor  ulcers  and  cicatrices  within  the  en- 
compassing ring,  the  extreme  slowness  of  the  process 
as  contrasted  with  the  extension  of  the  syphilitic  affec- 
tion, and  the  distinctly  verrucous  character  of  the  growth 
at  the  circumference   of  the   patch,  aid  in   establishing 


SYPHILIS   OF   THE   SKIN.  1 27 

a  diagnosis.  Again,  carcinomatous  disease  is  decidedly 
more  frequent  on  the  face  than  elsewhere,  while  the 
largest  of  the  syphilitic  lesions  are  usually  visible  on 
the  trunk   or  on  the   limbs. 

Tuberculosis  of  the  skin  (lupus  vulgaris  and  other 
forms)  is  so  very  rarely  encountered  with  truly  serpigi- 
nous characters  that  one  views  with  some  distrust  a 
diagnosis  of  "  serpiginous  lupus."  In  any  such  rare 
case  the  history  of  the  disease,  the  age  of  the  patient 
when  first  attacked,  the  characters  of  the  ulceration,  and 
the  other  distinguishing  features  of  the  lupoid  ulcer 
given  above,  should  suffice  for  the  determination  of  its 

nature. 

In  blastomycetic  dermatitis  the  diagnosis  is  assured 

only  after  careful  microscopical  examination  of  sections 

of  the  morbid  skin.     In  typical  cases  there  is  a  slowly 

spreading  papulo-pustular  and  verrucous  eruption,  leaving 

behind  it  a  cicatriform  area.     As  a  rule,  the  progress  of 

this    deforming    affection   is   much   slower  than  that  of 

syphilis. 

The  vegetating  syphiloderm  is  another  of  the  titles 
given,  not  to  a  special  cutaneous  lesion  of  syphilis,  but 
to  a  feature  which  may  be  assumed  by  one  or  more  of 
such  lesions.  In  these  cases  there  is  a  tendency  to 
assume  the  papillomatous  type,  with  hypertrophy  of  the 
epidermis  and  of  the  deeper  portions  of  the  skin.  These 
hypertrophies  usually  occur  as  complications  of  the 
moist  rather  than  of  the  dry  lesions  of  syphilis  in  the 
skin,  and  they  are  of  more  frequent  occurrence  in 
regions  where  there  is  both  unusual  heat  and  moisture. 
They  are  also  much  more  apt  to  develop  in  young  and 
fleshy  subjects  of  the  disease,  and  particularly  in  young 
and  fleshy  women. 

In  these  cases  wart-like  and  papillomatous  vegeta- 
tions develop  from  either  plane  macules  and  irritated 
surfaces  or  from  papules,  pustules,  condylomata,  or 
ulcerating  points.  They  vary  in  size  from  lenticular 
growths  to  masses  as  large  as  an  orange  and  even  much 


128      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

larger,  usually  secreting  a  foul-smelling  puriform  mucus 
from  the  side,  base,  or  summit  of  the  vegetation.  These 
growths  are  particularly  liable  to  occur  in  the  region  of 
the  scalp,  about  the  folds  of  the  axillae,  the  groins,  and 
the  nates,  and  about  the  anus.  The  rounded,  flattened, 
acuminate,  or  tufted  summits  of  these  excrescences  are 
usually  covered  with  crusts  due  to  the  desiccation  of  the 
puriform  secretion  with  which  they  are  smeared,  and  on 
the  removal  of  which  the  dull-reddish  or  florid  surface 
of  the  masses  can  be  distinguished.  When  removed 
artificially  or  spontaneously  the  superficial  character  of 
the  process  is  readily  determined. 

The  diagnosis  is  from  lupus,  pemphigus  vegetans, 
frambcesia,  yaws,  and  all  the  simple  papillomatous  and 
warty  growths.  The  distinction  between  the  skin- 
lesions  of  syphilis  and  the  two  diseases  first  enumerated 
has  already  been  given.  In  frambcesia  there  is  always 
an  absence  of  the  other  symptoms  usually  shown  in 
patients  with  vegetating  syphilodermata ;  the  subjects 
of  the  disease,  further,  are  chiefly  those  either  living  on 
or  recently  leaving  the  coasts  of  Africa.  The  creamy 
secretion,  the  acid  reaction,  and  the  shorter  career  of 
yaws  are  all  significant.  The  warty  growths  found  on 
the  scalp  and  elsewhere  of  persons  not  infected  with 
syphilis  often  present  features  strongly  resembling  the 
vegetating  lesions  here  described,  and  the  distinction 
between  them  all  is  to  be  looked  for  in  the  peculiar  cha- 
racters of  the  syphiloderm.  In  the  latter,  the  size  of  the 
single  or  the  abundance  of  the  frequently  multiple 
growths,  the  fetor  of  the  secretion,  and  the  accompany- 
ing symptoms  of  an  infective  disease  are  chiefly  to  be 
relied  upon  in  the  establishment  of  a  diagnosis. 

Syphilitic  Affections  of  the  Hair. 

The  most  important  of  the  changes  produced  by 
syphilis  in  the  hairs  is  an  alopecia,  important  both 
because  of  the  disfigurement  it  produces  and  because 
of  the  aid  it  furnishes  in  establishing  a  diagnosis  of  the 


SYPHILITIC  AFFECTIONS    OF  THE   HAIR.         1 29 

disease.  Syphilis,  however,  involves  the  nutrition  of 
the  hair  often  without  production  of  an  alopecia,  work- 
ing in  many  subjects  of  the  disease  a  special  dryness 
and  other  symptoms  of  malnutrition  without  fall  of  the 
hair  sufficient  to  be  conspicuous.  There  are  two  well- 
differentiated  forms  of  syphilitic  alopecia :  in  the  first 
form  the  loss  of  hair  is  due  simply  to  the  action  of  the 
virus  of  the  disease,  presumably  upon  the  nerves  of  the 
scalp ;  in  a  second  form  the  alopecia  is  directly  induced 
by  changes  in  the  scalp. 

Syphilitic  Alopecia  without  Obvious  Structural 
Change  in  the  Integument. — This  is  decidedly  the 
most  common  form  of  the  affection,  exhibiting  conspic- 
uous features  in  many  patients,  and  probably  occurring 
in  an  unobtrusive  form  in  the  great  majority  of  all  well- 
developed  cases.  It  may  coexist  in  the  same  person 
with  an  alopecia  due  to  structural  changes  ;  it  may  be 
partial  or  general,  though  the  latter  is  of  exceedingly 
rare  occurrence ;  and,  as  a  rule,  it  develops  among  the 
earliest  symptoms  of  systemic  intoxication.  At  times 
only  the  hair  of  the  scalp  is  affected ;  at  other  times 
the  scalp,  brows,  lids,  axillae,  and  extremities  are,  in  one 
or  several  regions,  made  partially  bald.  Usually  the 
hairs  of  other  regions  are  lost  only  when  the  scalp  is 
involved,  but  at  times  when  the  scalp  is  unaffected  the 
hairs  of  the  brows  or  of  the  beard  may  fall. 

All  grades  of  loss  are  perceptible,  from  that  escaping 
casual  observation  to  that  in  which  the  scalp  is  laid  bare 
over  wide  areas,  the  hairs  falling  in  large  numbers,  slight 
traction  upon  any  filaments  selected  at  once  bringing 
them  painlessly  from  their  pouches.  As  a  rule,  the 
resulting  deformity  is  manifested  to  the  eye  in  a  cha- 
racteristic "  raggedness  "  of  the  hirsute  covering,  bare 
patches  being  particularly  noticeable  over  the  temples 
and  the  occiput,  as  distinguished  from  the  pre-senile 
losses  often  seen  where  the  thinning  is  largely  limited  to 
the  vertex.  When,  however,  the  scalp  is  shaved  or  the 
hairs  are  clipped  close,  it  is   clear  that  the   loss  occurs 

9 


130      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

chiefly  in  finger-nail-sized  areas,  often  closely  set 
together,  never  producing  the  palm-sized,  completely 
bald  patches  of  most  non-syphilitic  diseases  accom- 
panied by  alopecia.  Upon  the  eyebrows  the  loss  is 
often  highly  conspicuous  by  reason  of  its  lack  of  sym- 
metry, the  hairs  of  one  brow,  for  example,  being 
removed  when  the  other  is  intact,  or  one-half  of  the 
hairs  falling  from  one  or  the  other  extremity  of  the  brow 
of  one  side.  The  conspicuousness  of  these  forms  of 
alopecia  makes  them  most  offensive  to  the  conscious 
subjects  of  the  disease.  When  the  loss  involves  the 
region  of  the  male  beard,  the  patches  are  usually  similar 
to  those  seen  on  the  shaven  scalp ;  but  occasionally  a 
baldness  of  the  bearded  face  occurs  in  large  patches 
which  it  is  difficult  to  distinguish  from  alopecia  areata. 
Syphilitic  Alopecia  due  to '  Structural  Changes  in 
the  Integument. — In  these  cases  the  alopecia  is  con- 
secutive to  the  evolution  of  a  syphiloderm  in  the  region 
of  the  skin  affected  with  the  hair-loss.  The  pre-existing 
lesion  in  the  best-marked  cases  is  then  of  an  ulcerative 
type,  resulting  in  a  destruction  of  tissue  limited  to  the 
area  where  the  loss  of  hair  occurs ;  in  this  event  even 
the  baldness  is  often  a  minor  symptom  when  compared 
with  the  graver  metamorphoses  of  the  skin  in  which 
the  hairs  were  once  implanted.  Other  syphilodermata 
may,  however,  be  responsible  for  the  alopecia,  such  as 
macular,  papular,  papulo-pustular,  and  tubercular  lesions, 
as  also  gummata,  the  latter  involving  also  the  subcu- 
taneous structure.  Most  of  these  lesions  are  effec- 
tive by  actual  destruction  of  the  hair-follicle  by  either 
ulcerative  or  resolutive  changes  following  the  syphilitic 
deposit.  As  compared  with  the  simpler  form  of  alopecia 
previously  described,  it  is  noticeable  that  the  alopecia  due 
to  structural  change  in  the  skin  is  often  remediless,  while 
the  former  is  almost  invariably  followed  by  a  return  of  the 
hairs  ;  that  the  tissue-change  is  most  often  circumscribed 
and  limited  to  a  single  region  of  the  body,  particularly 
the  scalp;  and  that  the  alopecias  of  early  syphilis,  which 


SYPHILITIC  AFFECTIONS   OF  THE  HAIR.         13I 

are  often  multiple  and  unaccompanied  by  destructive 
changes,  differ  widely  in  every  feature  save  the  hair-loss 
from  the  invasions  of  the  hair-sacs  by  the  late,  usually 
gummatous,  deposits  of  the  disease.  When  the  milder 
forms  of  consecutive  alopecia  occur,  they  often  result 
from  a  species  of  syphilitic  involvement  of  the  sebaceous 
glands  of  the  scalp  and  of  other  regions,  finger-nail- 
sized  patches  of  the  part  involved  being  covered  with 
fine,  often  greasy  scales,  the  integument  being  manifestly 
hyperaemic  and  tinted  in  the  dull-reddish  hues  of  the 
syphilitic  macule. 

Diagnosis. — In  almost  all  forms  of  syphilitic  alopecia 
the  diagnosis  is  established  by  the  discovery  of  other 
symptoms  of  the  disease,  which,  as  a  rule,  may  be  dis- 
covered if  sought  for  with  special  care.  It  is,  however, 
true  that  in  exceptional  cases  the  force  of  the  first  in- 
toxication of  the  system  seems  to  expend  itself  wholly 
upon  the  hirsute  covering  of  the  body,  and  in  these 
losses  it  may  be  a  matter  of  difficulty  to  discover  the 
site  of  the  original  chancre  and  its  possibly  persistent 
underlying  sclerosis. 

Alopecia  areata  most  strongly  resembles  the  syphi- 
litic form  of  baldness,  but  in  the  former  the  patches 
are  usually  large,  the  skin  denuded  of  hairs  ,is  smooth 
and  white,  the  line  of  demarcation  after  the  few  hairs 
that  are  loosened  at  the  periphery  have  been  epilated  is 
much  more  distinctly  outlined  by  vigorous  filaments, 
and,  seeing  that  children  are  not  rarely  affected,  the  sub- 
jects of  the  disease  are  at  times  much  younger  than 
those  suffering  from  acquired  syphilis. 

The  congenital,  pre-senile,  and  senile  losses  of  hair 
are  usually  symmetrical  and  permanent ;  they  occur  at 
epochs  of  life  which  commonly  contrast  with  the  average 
age  of  acquisition  of  syphilis,  the  exception  occurring  in 
pre-senile  forms  of  baldness,  where  there  is  usually  a 
definite  history  of  preceding  seborrhceic  trouble.  The 
simpler  varieties  of  baldness  are,  however,  of  much 
longer  duration  than  the  common  forms  of  syphilitic 


I32      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

alopecia.  In  ringworm  of  the  scalp  the  presence  of  the 
parasite  and  the  commonly  tender  age  of  the  subject  of 
the  disease  are  significant.  In  psoriasis  of  the  scalp  the 
highly  characteristic  scale-accumulation,  often  extending 
beyond  the  confines  of  the  scalp  at  the  brow,  is  a  diag- 
nostic feature. 

Syphilitic  Affections  of  the  Nail. 

It  is  usual  to  distinguish  between  two  different  forms 
of  syphilitic  invasion  of  the  nail  and  its  peripheral  tissues, 
the  term  paronychia  being  employed  to  designate  the 
changes  in  the  nail-substance  which  are  consecutive  to 
those  occurring  in  the  tissues  about  the  nail ;  while  the 
term  onychia  is  limited  to  changes  occurring  primarily,  as 
regards  obvious  symptoms,  in  the  nail  itself.  The  two 
conditions  may  coexist.  The  distinction  is,  however, 
though  useful  for  clinical  purposes,  scarcely  based  upon 
pathological  facts,  seeing  that  it  is  highly  probable  that 
no  changes  whatever  occur  in  the  nail  proper  prior  to  dis- 
turbances in  the  nervous  or  other  structures  with  which 
it  is  in  relation. 

Changes  in  the  Tissues  Surrounding  the  Nail,  with 
or  without  Consecutive  Lesions  of  the  Latter  (Par- 
onychia syphilitica). — In  the  more  superficial  variety  of 
this  disorder  the  epidermis  and  often  the  deeper  portions 
of  the  skin  in  a  circumscribed  patch,  usually  at  one  ex- 
tremity of  the  nail-groove,  thicken  and  assume  a  warty 
aspect.  This  local  thickening  may  be  resolved  in  suc- 
cessive exfoliations  with  some  resulting  tenderness,  or 
there  may  be  superficial  excoriations,  fissures,  or  even 
resulting  ulcers.  One  or  several  digits  may  be  involved, 
the  fingers  more  often  than  the  toes,  on  account  of  the 
exposure  of  the  former  in  the  occupations  of  life.  Some- 
times the  integument  of  one  or  several  joints  of  the  digit 
is  implicated  in  the  process.  This  complication  occurs 
within  a  few  months  after  infection,  or  it  may  be  delayed 
to  one  or  two  years  after — rarely  the  latter.  It  is  most 
often  contemporaneous  with  maculo-papular  and  papulo- 


Plate  15. 


SYPHILITIC  AFFECTIONS   OF   THE   NAIL.         I  33 

squamous  lesions  of  other  regions.  The  consecutive 
changes  in  the  nail,  when  such  occur,  are  of  the  milder 
types  elsewhere  described. 

In  a  deeper  form  of  involvement  of  the  tissues  about 
the  nail,  a  nodule,  dull  ham-tinted  and  tender,  varying 
in  size  from  that  of  a  pea  to  that  of  a  bean,  forms  either 
in  the  nail-fold,  the  nail-groove,  or  the  matrix,  usually 
upon  one  side.  Occasionally  the  more  prominent  skin- 
symptom  is  a  deep  and  ill-defined  infiltration.  The 
cracking  and  exfoliation  seen  in  the  superficial  form 
may  be  conspicuous  in  the  deeper  form  of  the  disease, 
the  infiltration  undergoing  in  favorable  cases  complete 
resolution  under  appropriate  treatment,  though  its  course 
is  commonly  indolent.  In  other  cases  ulceration  ensues, 
the  part  becomes  tender,  at  times  exceedingly  painful, 
and  the  pus  which  may  be  discharged  gives  no  such 
relief  as  in  the  "  run-around,"  the  course  of  which  is  much 
more  brief.  The  affection  persistently  lingers  when  the 
toes  are  involved.  The  odor  of  the  secretions  furnished, 
especially  by  the  great  toe,  which  on  account  of  its 
prominence  often  suffers,  is,  as  usual  in  this  region, 
often  highly  offensive. 

Ulceration,  whether  resulting  from  the  superficial  or 
the  deeper  involvement  of  the  parts  about  the  nail, 
occurs  as  a  complication  of  both  processes  in  various 
grades.  The  course  of  such  complications  is  always 
modified  by  treatment.  As  usual,  the  fingers  and  the 
great  toe,  for  reasons  already  explained,  suffer  more 
than  the  other  digits. 

The  ulcer,  whether  starting  from  nail- fold  or  matrix, 
assumes,  as  a  rule,  with  startling  rapidity  its  formid- 
able features.  The  edges  of  the  ulcer  are  raised,  often 
undermined;  the  floor  is  covered  with  an  unhealthy, 
partly  purulent  slough,  usually  well  attached,  with 
dull-colored  granulations  springing  from  its  mass.  The 
color  of  the  whole  is  characteristically  empurpled  and 
unhealthy.  The  prominent  club-shaped  aspect  of  the 
distal  phalanx,  swollen  to  two  or  three  times  its  usual 


.134      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

volume,  presents  a  vivid  contrast  with  the  adjacent  and 
unaffected  phalanx,  which  seems  in  comparison  to  be 
shrunken  or  atrophied.  Viewed  at  a  distance,  the 
deformity  often  seems  to  be  produced  by  a  pushing 
of  the  nail-substance,  whether  involved  or  not,  far  to  one 
side  of  the  longitudinal  axis  of  the  digit,  the  reason  for 
this  being  the  bulk  of  the  swollen  and  inflamed  tissues 
on  one  side  of  the  phalanx.  The  nail  may  be  lost  or 
partially  destroyed  in  the  process.  The  new-formed  nail 
may  be  misshapen  or  well  formed.  As  a  rule,  the  repair 
procured  by  the  best  treatment  is  surprisingly  good  in 
view  of  the  marked  deformity  and  the  threatening  cha- 
racter of  the  lesions,  especially  when,  as  may  be  the  case, 
many  of  the  fingers  are  simultaneously  attacked. 

This  complication,  usually  occurring  in  the  first  two 
years  after  infection,  is  often  a  portent  of  grave  syphilis ; 
it  is  apt  to  occur  in  middle-aged  patients  with  broken- 
down  constitutions. 

Changes  in  the  Nail,  with  and  without  Involvement 
of  the  Adjacent  Tissue  (Onychia  syphilitica). — (a) 
Atrophic  Changes  in  the  Nail. — Every  grade  of  atrophy 
of  the  nail  may  occur  in  syphilis,  and  the  milder  forms 
are  much  more  common  than  is  generally  supposed. 
They  are  often  detected  by  the  expert  in  his  examina- 
tions when  they  escape  the  attention  of  the  patient.  In 
the  simpler  manifestations  the  nail-substance  loses  its 
lustre,  acquires  a  dirty-yellowish  hue,  and  slowly  covers 
itself  with  various  striations,  markings,  dots,  and  spots, 
often  presenting  a  characteristic  "  worm-eaten  "  appear- 
ance. The  friability  of  the  nail  is  increased  to  a  per- 
ceptible extent,  and  its  broken  or  nicked  free  edge  is  seen 
in  many,  if  not  all,  the  digits,  especially  those  of  the 
fingers  {pnyxis  craqiiele  of  the  French). 

(b)  Hypertrophic  Changes  in  the  Nail  (Syphilitic  on- 
ychauxis).— In  this  form,  which  may  coexist  with  the 
atrophic  changes  described  above,  and  which  is  rarer 
than  all  others,  portions  only  of  the  nail  may  be  per- 
ceptibly thickened  by  increased   growth,   or   the  entire 


SYPHILITIC  AFFECTIONS   OF  THE   NAIL.         1 35 

nail  may  be  enormously  increased  in  bulk,  changed  in 
color,  and  marked  by  the  pinhead-sized  dots  or  depres- 
sions, sharply  cut  in  outline,  where  small  circumscribed 
atrophic  changes  have  occurred. 

(c)  Separation  of  the  Nail  from  Matrix,  Bed,  or  Fold. 
— This  change,  an  exceedingly  common  one  in  syphilis, 
may  involve  one  or  all  the  nails  of  the  hands  and  the 
feet.  As  a  rule,  several  of  the  digits  are  affected,  the 
hands  by  preference.  The  detachment  may  be  partial 
or  total. 

Among  partial  detachments,  much  more  common  than 
all  others,  the  mildest  is  seen  in  early  periods  after  infec- 
tion. The  separation  usually  occurs  first  at  the  distal 
extremity  of  the  nail  where  it  is  attached  to  the  side  of 
the  nail-bed,  and  is  visible  beneath  the  nail-substance 
as  a  delicate  linear  or  ribbon-like  stripe,  parallel  with 
the  long  axis  of  the  nail,  resembling  a  serous  exudation 
beneath  the  nail-substance ;  or  the  line  of  separation  is 
whitish  in  hue,  and  the  separation  occurs  at  the  bottom 
of  the  nail-groove  or  across  the  entire  width  of  the  nail. 
One-half  or  more  of  the  nail  may  thus  be  detached  from 
its  connections,  the  separated  substance  undergoing  the 
usual  changes  in  color  and  polish. 

When  the  separation  is  complete,  it  may  result  from 
changes  beginning  as  in  the  partial  forms  described 
above,  or  with  changes  in  the  matrix,  the  latter  being 
more  common.  Usually  the  latter  ceases  to  provide  for 
the  further  growth  of  the  nail-substance,  and  the  nail 
which  is  to  be  shed  is  simply  slid  along  its  nail-fold 
until  it  is  exfoliated,  undergoing  meanwhile  the  atrophic 
changes  already  described,  in  markings,  striations,  etc. 
upon  its  surface.  When  the  nail-bed  is  left  bare  it  is 
speedily  covered  with  a  substance  which,  in  all  favor- 
able cases,  eventually  furnishes  a  new  nail. 

Variations  from  this  type  are  furnished  by  defective 
and  imperfect  attempts,  instead  of  by  total  cessation  of 
effort,  of  the  matrix  to  furnish  the  nail-substance.  In 
the  former  event  ridges  of  mingled  atrophic  and  hyper- 


136      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

trophic  nail-substance  mark  the  boundaries  between  the 
diseased  plate,  newly  formed,  and  the  healthier  nail  pro- 
duced prior  to  the  date  of  the  infective  process.  As  a 
result  the  nail  is  shed,  and  its  successor  is  formed  after 
a  lapse  of  time  in  which  the  nail-bed  is  in  part  exposed 
and  beset  by  imperfectly  formed,  thinned,  irregular,  or 
"  worm-eaten  "  fragments  of  horny  substance. 

Diagnosis. — In  general,  the  nature  of  the  disorder  of 
the  nails  is  readily  established,  as  there  is  usually  a  his- 
tory, and  in  almost  every  instance  other  symptoms,  of 
infection.  The  indolent  course  of  the  disease,  the  tend- 
ency to  ulceration  of  the  soft  parts  about  the  nail,  and 
the  deformity  resulting  in  the  production  of  a  bulbous 
or  club-shaped  distal  phalanx,  are  all  significant.  In- 
growing toe-nail,  chiefly  of  the  large  toe,  presents  an 
obvious  explanation  for  the  tumefaction  and  pain. 
Chancres  seated  in  the  site  of  a  "  hang-nail,"  especially 
among  physicians  infected  in  the  practice  of  their  pro- 
fession, are  commonly  associated  with  enlargement  and 
induration  of  the  epitrochlear  gland  of  the  limb  involved. 
Tuberculous  affections  from  inoculation  of  the  manual 
digits  are  rarely  situated  at  the  nail-border,  and  they  are 
usually  of  verrucous  rather  than  of  papular  type. 

Syphilis  of  the  Mouth  and  the  Tongue. 

The  study  of  syphilis  as  it  affects  the  mouth  is  of 
great  importance  because  of  the  frequent  implication  of 
this  cavity,  because  of  the  persistence  and  significance 
of  the  symptoms  presented,  and  because  of  the  amply 
afforded  possibilities  of  transmission  of  the  disease.  In 
such  a  region  as  this  is  well  illustrated  the  tendency 
of  the  disease  to  exhibit  its  symptoms  at  sites  of  special 
irritation.  The  chewing  and  smoking  of  tobacco,  the 
holding  of  pipes,  cigars,  and  cigar-holders  in  the  mouth, 
and  even  the  practice  of  chewing  a  toothpick  after 
meals,  are  fruitful  sources  of  lesions  in  this  region 
of  the  body.     The  drinking  of  very  hot  or  iced  fluids 


SYPHILIS   OF  THE   MOUTH  AND    TONGUE.       1 37 

and  the  use  of  highly-spiced,  acetous,  or  salted  foods 
have  a  similar  tendency. 

Chancres  occurring  upon  the  tongue,  the  lips,  and  the 
tonsils  have  been  considered  elsewhere.  It  is  needful 
here  to  recall  the  fact  that  lesions  suggesting  in  appear- 
ance mucous  patches  of  the  tonsils,  with  an  ashen  sur- 
face and  deep  engorgement,  deep  indurations  of  the 
anterior  segment  of  the  tongue  capped  with  a  super- 
ficial abrasion  or  ulcer,  and  circumscribed  scleroses  with 
much  tumefaction  of  the  inside  of  the  cheek  or  the 
gum,  if  associated  with  dense  induration  of  the  glands 
anatomically  connected  with  these  parts,  should  not 
hastily  be  taken  for  symptoms  of  consecutive  syph- 
ilis. 

The  lesions  of  systemic  syphilis  in  the  oral  cavity  are, 
when  more  or  less  speedily  succeeding  the  appearance 
of  the  chancre,  usually  superficial,  multiple,  and  well- 
nigh  symmetrical,  as  distinguished  from  those  occurring 
later  in  the  disease,  which  are  often  single  and  deep  as 
well  as  destructive. 

These  lesions  correspond  strictly  with  those  already 
studied  as  of  occurrence  in  the  skin,  being  of  the  type 
of  macules,  papules,  tubercles,  warts,  scales,  pustules, 
gummata,  and  ulcers.  Each  type,  however,  acknow- 
ledges a  modification  due  to  the  peculiarities  of  site, 
the  mouth  being  habitually  moistened  with  mucus  and 
saliva,  and  being  exposed  to  friction  of  contiguous  sur- 
faces and  of  articles  of  ingested  food  and  drink,  which, 
as  already  shown,  add  the  effect  of  heat,  cold,  and 
chemical  agents  to  the  other  effective  causes  of  disease 
in  this  region.  Again,  the  pressure  upon  the  tongue 
and  the  inner  face  of  the  cheeks  of  carious  and  even 
sound  teeth  having  projecting  edges,  not  appreciated  in 
conditions  of  health,  is  capable  of  inducing  or  modifying 
the  symptoms  here  presented.  As  a  rule,  however,  the 
syphilitic  lesions  of  the  mouth  are  of  moist  rather  than 
of  dry  type,  with  the  result  that  the  mucous  patch  is 
probably  of  greater  frequency  as  a  syphilitic  symptom 


138      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

than  any  other  lesion  exhibited  in  the  course  of  the  dis- 
ease, particularly  in  male  patients  using  tobacco. 

Macular  Syphilis  of  the  Mouth. — Well-defined 
broad  areas  of  vivid  or  dusky  redness  may  often  be  seen 
over  the  arch  of  the  soft  palate,  upon  the  tongue  and 
the  pillars  of  the  fauces,  and  along  the  gingivo-labial 
furrows  soon  after  general  syphilis  is  declared.  At 
times  the  redness  is  limited  to  finger-nail-sized  plaques, 
or  even  punctate  spots  of  heightened  color,  upon  the 
mucous  membrane.  These  spots  may  disappear  on 
proper  treatment,  or  they  may  persist  and  furnish  a  basis 
for  the  evolution  of  one  or  more  of  the  other  lesions  to 
be  mentioned. 

The  chief  complication  of  patches  of  this  type  is  the 
assumption  of  an  erosive  and  superficial  or  ulcerative 
and  deep  action,  due,  as  a  rule,  to  the  irritant  effect  of 
the  agencies  already  described.  In  milder  expression 
the  epithelium  loses  its  attachment  to  the  underlying 
tissue  in  consequence  of  a  macerative  effect  upon  the 
weakened  membrane,  and  the  reddish  pellicle  first  seen 
on  examination  disappears,  leaving  a  raw-looking  and 
tender  spot  the  size  of  the  original  macule.  In  other 
cases  a  sharply-cut  ulcer  results,  with  floor  more  or  less 
speedily  extending  to  the  depth  of  the  mucosa,  assuming 
a  linear  shape  with  its  long  axis  at  right  angles  to  the 
lines  of  traction  (along  the  width  of  the  tongue,  parallel 
with  the  groove  of  the  gingivo-labial  junction,  etc.). 

The  papular  syphiloderm  is  represented  on  mucous 
surfaces  by  the  mucous  patch  {plaque  maqueiise,  mucous 
tubercle,  moist  papule,  etc.).  These  lesions  are  single  or 
more  commonly  multiple,  usually  very  well  defined 
patches,  which,  being  at  first,  and  usually  but  for  a 
brief  time,  reddened  macules,  speedily  acquire  an  opaline 
hue  over  their  flat  surface,  suggesting  the  action  of 
nitrate  of  silver  upon  mucous  membrane.  They  vary  in 
size  from  a  split  pea  to  that  of  a  bean,  but  they  are  often 
of  greater  size,  involving  a  space  as  large  as  a  penny  or 
as  extensive  as  the  inner  face  of  the  lip  or  the  arch  of 


Plate  16. 


Mucous  patches  of  the  lips  (Mracek). 


LUh .  Arist  /■:  Reichhold,  Munch 


SYPHILIS   OF   THE   MOUTH  AND    TONGUE.        1 39 

the  palate.  They  are  roundish,  oval,  or  very  irregular 
in  contour,  and  they  are  often  perceptibly  raised  above 
the  general  level.  They  are  usually  painful,  and  they 
are  often  seen  en  face  on  membranes  in  contact,  such 
as  the  inner  face  of  the  cheek  and  the  gum,  and  the  two 
halves  of  the  angular  crevice  behind  the  last  molar 
teeth.  A  variation  of  this  lesion  is  seen  when  a  diph- 
theroid and  bulkier  film  extends  over  the  face  of  the 
patch  or  patches. 

The  most  common  complication  of  this  lesion  is  the 
superficial  erosion  which  succeeds  it,  and  which  becomes 
visible  as  a  vivid  or  dull-reddish,  moist  and  shining  or 
dry  and  glazed  sequel  of  the  removal,  by  friction  or 
other  agency,  of  the  pellicle  of  epithelium  covering  the 
typically  developed  mucous  patch.  The  elevation  of 
these  plaques  by  infiltration  is  not  uncommon,  and  a 
further  but  rarer  complication  is  furnished  when  this 
hypertrophic  effect  is  exaggerated.  In  the  latter  event 
a  well-elevated  roundish  disk,  obviously  thickened,  and 
often  with  a  distinctly  elevated  rim,  rises,  especially 
within  the  labial  angles,  but  also  elsewhere  ;  this  disk  is 
usually  less  painful  than  the  simplest  expression  of  the 
mucous  patch,  and  is  annoying  chiefly  by  reason  of  its 
interference  with  the  motions  of  the  mouth.  Often  it 
is  traversed  by  one  or  more  fissures,  which  are  then 
painful  and  apt  to  bleed  when  the  tissue  is  unusually 
stretched. 

Papules  of  moist  type — seen  on  mucous  membranes, 
and  much  more  rarely  in  the  mouth  than  about  the 
vulva  or  the  anus — also  at  times  assume  a  verrucous 
aspect,  and  are  represented  by  growths  resembling  the 
pointed  wart  or  the  venereal  wart,  already  described. 
They  are  usually  smaller  in  the  mouth  than  in  the  other 
regions  where  they  occur,  they  do  not  furnish  an  offen- 
sive secretion,  and  they  are  more  amenable  to  local 
treatment.  The  so-called  "  toad's-back  "  appearance  of 
the  tongue  is  produced  by  the  confluence  of  a  number 
of  flattish  and  aggregated   papules,  each    retaining   its 


140      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

individual  outlines,  and  producing  thus  an  effect  resem- 
bling the  markings  on  the  carapace  of  a  terrapin. 

Ulcerative  complications  of  the  papules  of  syphilis  in 
the  mouth  (mucous  patches,  etc.)  are  of  the  type  already 
described,  superficial  and  often  exquisitely  painful  in  the 
earlier  and  less  irritative  stages,  deeper  and  reaching  to 
the  corium  and  beyond  in  the  greatly  irritative  and  later 
lesions  of  the  disease.  Ulcers  here  have  a  marked  tend- 
ency to  creep  along  the  lines  traced  by  the  angles  of 
adjacent  surfaces,  but  they  also  occur  as  formidable 
circular  lesions  in  the  crypts  of  the  tonsil,  on  the  poste- 
rior wall  of  the  pharynx,  and  on  the  inside  of  the  lips. 

Tubercular  lesions  of  mucous  membranes  are  simply 
enlarged  papules  developing  with  complications  of  the 
types  described  above.  Pustules  occurring  in  the  syph- 
ilitic mouth  are  results  of  secondary  infection  with  staph- 
ylococci ;  they  are  usually  seen  only  after  rupture  of  the 
roof  of  the  lesion,  when  the  floor  of  the  original  chamber 
is  to  be  recognized  as  an  erosive  or  ulcerative  patch. 

The  fissures  which  form  as  a  result  of  syphilis  of  the 
mouth  may  be  complications  of  one  or  several  of  the 
lesions  described  above,  or  may  be  the  direct  results  of 
local  irritation  at  certain  special  sites.  These  sites  are 
the  outer  angles  of  the  lips,  often  involving  both  the 
mucous  and  cutaneous  surfaces,  the  margins  and  dorsum 
of  the  tongue,  and  the  muco-cutaneous  borders  of  the 
centre  of  the  lips ;  but  they  also  develop  elsewhere. 
Care  is  required  to  recognize  even  deep  longitudinal  fis- 
sures of  the  tongue,  the  walls  of  the  crevices,  when  the 
organ  is  protruded,  often  falling  together  and  wholly 
concealing  a  crack  extending  deeply  beneath  the  mucous 
membrane. 

The  squamous  lesions  of  syphilis  in  the  mouth  are  of 
the  type  usually  described  as  "  dry,"  the  failure  of  secre- 
tion at  the  involved  points  being  usually  conspicuous. 
They  appear,  rather  more  rarely  than  mucous  patches, 
on  the  borders  of  the  tongue,  on  the  inner  aspect  of  the 
lips,   on  the  lingual  tonsil,  and  along  the  line   of  the 


SYPHILIS   OF   THE   MOUTH  AND    TONGUE.        141 

inner  faces  of  the  cheeks  corresponding  with  the  junction 
of  the  teeth  of  the  upper  and  lower  jaws.  They  are 
dry,  infiltrated,  and  usually  circumscribed  patches, 
rarely  as  uniformly  rounded  or  oval  in  contour  as 
mucous  patches,  and  linear  in  shape  or  in  ribbon-like 
bands.  Their  color  is  grayish  or  bluish-white,  occasion- 
ally almost  silver-white  with  a  lustrous  aspect.  Often, 
when  seated  upon  the  tongue,  the  affected  organ  has  a 
shaven  appearance,  the  French  from  this  circumstance 
giving  to  this  condition  the  term  glossite  tonsurante* 
Livid,  opaline,  bluish-white,  slate-tinted,  and  otherwise 
colored  patches  of  thickened  and  scaling  epidermal  tissue 
are  often  seen  in  the  mouths  of  syphilitic  patients,  espe- 
cially of  men  who  have  been  chewers,  and  more  fre- 
quently smokers,  of  tobacco.  These  conditions  may  be 
observed  in  the  first,  second,  or  any  subsequent  year 
after  the  date  of  infection.  They  are  at  times  amenable 
to  treatment,  but  they  are  often  refractory. 

Leucoplasia  of  the  Mouth  (Leucokeratosis  linguae ; 
Leucoma  buccae;  Psoriasis  linguae  ;  Leucoplakia  buc- 
calis  ;  "  Smoker's  patches  of  the  mouth,"  etc.). — It  is 
impossible  to  study  the  scaly  patches  of  the  mouth 
occurring  in  syphilis  without  considering  a  series  of 
phenomena  exhibited  in  this  region,  the  pathological  and 
clinical  position  of  which,  with  respect  to  syphilitic  and 
other  disease,  is  not  yet  completely  established.  By 
no  distinctive  features  can  these  symptoms  be  in  each 
case  assigned  with  certainty  to  one  category  or  an- 
other. They  stand  in  different  cases  in  some  relation 
to  syphilis,  to  epithelioma,  and  to  lichen  planus.  What 
is  definitely  known  can  be  summarized  as  follows :  In 
male  patients,  almost  exclusively  in  smokers,  but  also 
in  others,  appear  patches,  striae,  spots,  plaques,  fan- 
shaped  lesions,  and  bands  of  a  dull-whitish,  opaline, 
lead-white  and  silver-white  tint,  smooth  and  shining  or 
roughened  and  beset  with  milium-sized  nodules,  which 
are  consecutive  to  mucous  patches  or  which  occur  in 
the    mouths    of  syphilitic  patients  where  such  lesions 


I42      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

have  existed.  They  occur  along  the  line  of  the  jaws, 
on  the  gums,  at  the  commissure  of  the  maxillae,  in  the 
folds  between  the  lips  and  the  gums,  on  the  sides  and 
dorsum  of  the  tongue,  and  elsewhere.  They  may  be 
the  seat  of  fissures  or  may  result  in  ulceration.  In 
rare  cases  they  exfoliate  ;  still  more  rarely  there  may 
occur  a  highly  exaggerated  hypertrophy  of  the  impli- 
cated tissue,  in  which  a  stripe  of  dead-white,  thickened, 
and  exceedingly  dry  tissue  covers  the  dorsum  of  the 
tongue  or  one  of  the  other  regions  named  above,  this 
tissue  being  so  bulky  as  seriously  to  interfere  with  the 
necessary  movements  of  the  mouth.  Epithelioma,  not 
only  in  those  of  advanced  years  but  in  men  of  middle 
age,  is  liable  to  result  from  the  long-continued  irritation 
of  the  part.  In  other  cases  the  disease  is  without  ques- 
tion a  lichen  planus  of  the  mouth,  not  to  be  distin- 
guished as  to  etiology  from  the  other  patches  here 
described,  seeing  that  lichen  planus  of  the  integument 
often  responds  to  a  very  marked  extent  to  the  agents  by 
which  the  involved  tissue  is  irritated. 

It  is  practically  impossible  in  many  cases  to  draw  a 
distinction,  merely  from  the  clinical  appearance,  between 
these  several  symptoms,  nor  is  the  fact  greatly  to  be  re- 
gretted. The  leucoplasic  condition  is,  in  fact,  not  a  disease, 
but  a  symptom  common  to  several  diseases.  As  pigment 
settles  about  the  syphilitic  and  eczemato-varicose  ulcer 
of  the  leg,  and  as  the  elephantiasic  affection  of  the  same 
organ  occurs  as  a  complication  of  syphilis,  lymphangitis, 
erysipelas,  and  other  maladies,  so  the  scaling  patches  of 
the  tongue  irritated  by  tobacco-smoke,  carious  teeth, 
neglect,  and  bad  treatment  form  in  both  the  syphilitic 
and  the  non-syphilitic  patient,  in  the  victim  of  lichen 
planus  and  in  the  patient  who  eventually  succumbs  to  a 
grave  cancerous  affection  of  the  mouth.  It  is  safe,  in 
all  cases  admitting  of  any  doubt,  either  carefully  to  ex- 
clude the  possibility  of  syphilitic  infection  or  to  treat 
the  patient  for  that  disorder. 

Gummata  of  the  Mouth. — Gummata  occur  in  all  the 


Plate  17. 


SYPHILIS   OF   THE  MOUTH  AND    TONGUE.       143 

regions  of  the  mouth  as  circumscribed  or  diffuse  infiltra- 
tions, but  they  are  most  often  encountered  in  the  mass 
of  the  tongue,  usually  on  one  side,  with  well-defined 
limitations.  They  begin  as  insidiously  evolved  pin-head 
to  small-egg-sized  masses,  usually  single,  at  times  mul- 
tiple, though  rarely  numerous,  breaking  down  into 
ragged  ulcers  with  a  rapidity  and  a  facility  not  noted 
in  the  course  of  similar  lesions  of  the  derma.  They 
occur,  as  a  rule,  several  years  after  infection,  but  in  ob- 
tinate  users  of  tobacco,  especially  in  chewers  (as  dis- 
tinguished from  smokers,  who  suffer  from  mucous  and 
scaly  patches),  they  have  been  seen  as  early  as  during 
the  first  year  of  infection. 

When  the  hard  palate  is  involved,  it  is  common  to 
discover  in  nearly  the  centre  of  the  palatine  vault  a  len- 
til-sized firm  mass,  which  with  astonishing  rapidity 
softens  until  it  exhibits  a  central  orifice  through  which  a 
probe  can  detect  dead  bone.  In  other  cases  a  painless 
or  possibly  slightly  tender  gummatous  nodule  of  the  hard 
palate  may  persist  for  months  without  softening,  atten- 
tion being  called  to  it  by  a  persevering  explorer  of  the 
case  of  a  patient  suffering  from  some  other  obscure  symp- 
tom of  the  disease,  upon  which  important  light  is  shed 
by  the  discovery  of  the  oral  lesion.  When  very  large 
gummata  form  and  rapidly  disintegrate,  the  result  in 
grave  cases  is  only  equalled  by  the  severe  ravages  of 
cancer  in  the  same  region.  The  oral  and  nasal  cavities 
are  in  these  cases  rapidly  fused  until  they  expose  to  view 
a  single  gaping  chasm,  with  the  possibility  of  perform- 
ance, imperfect  yet  surprisingly  satisfactory,  of  neces- 
sary function.  Here,  as  so  often  in  the  history  of 
destructive  syphilis,  the  repair  wrought  by  skilful  treat- 
ment is  extraordinarily  happy  in  results.  The  huge 
clefts  and  cavities  of  the  tongue  close,  with  the  produc- 
tion of  a  sound  scar-tissue  which  may  resist  disease  for 
the  remainder  of  life,  and  from  which  one  can  scarcely 
estimate  the  degree  of  the  original  damage.  The  use 
of  an  obturator,  after  all    ulcers  have  been  healed,  by 


144      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

cutting  off  the  nasal  from  the  oral  cavity  may  restore  to 
the  voice  its  natural  timbre.  All  these  grave  changes 
occur  in  broken-down  subjects  of  disease,  or  in  those 
from  some  cause  specially  predisposed  to  complications 
of  this  character. 

Atrophy  and  Hemiatrophy  of  the  Tongue  in  Syphi- 
lis.— In  some  cases  a  gummatous  deposit  affects  the  follic- 
ular glands  near  the  base  of  the  tongue,  which  later  under- 
goes resolution,  with  the  result  of  leaving  a  portion  of  the 
organ  in  an  atrophic  state,  smooth,  wasted,  and  firm.  In 
rarer  instances  one-half  only  of  the  organ  is  involved  in 
the  same  process.  These  changes  coincide,  as  a  rule, 
with  characteristic  symptoms  of  the  disease  in  other 
parts  of  the  mouth. 

Diagnosis. — The  distinction  between  scaly  patches, 
lichen  planus,  and  smoker's  patches  has  already  been 
considered.  Cases  are  of  frequent  occurrence  where  a 
differential  diagnosis  is  impossible,  for  the  reason  already 
given — that  the  conditions  described  under  these  terms 
are  often  symptoms  common  to  several  diseases.  Mer- 
curial stomatitis  with  ulceration  is  readily  distinguished 
by  the  fetor  of  the  breath,  the  symmetrically  swollen  con- 
dition of  the  tongue,  the  indentation  of  its  sides  by  the 
teeth,  and  the  line  at  the  border  of  the  gums.  The  con- 
dition known  as  exfoliatio  areata  linguce  (a  phrase  de- 
scribing symptoms  rather  than  a  disease)  is  characterized 
by  the  occurrence,  especially  in  subjects  of  a  tender 
age,  though  adults  also  suffer,  of  a  well-defined  elevated 
patch  spreading  in  circular  outline  over  the  tongue  in 
areas  as  large  as  a  penny  and  larger,  leaving  the  tissue 
where  it  has  extended  smooth  and  varying  in  color, 
in  different  cases,  from  a  light  rosy  shade  to  an  em- 
purpled hue.  Often  the  patch  dips  down  over  the  tip 
or  the  sides  of  the  tongue.  The  area  is  commonly  uni- 
lateral in  site,  not  often  symmetrically  involving  the  two 
sides  of  the  organ.  However  much  these  areas  may  sug- 
gest syphilis,  they  are,  as  a  matter  of  fact,  rarely  seen  in 
that  disease.     In  some  cases  they  are,  without  question, 


SYPHILIS   OF  THE  MOUTH  AND    TONGUE.       145 

the  result  of  grinding  the  tongue  between  the  teeth  in 
the  sleep  of  young  patients  with   digestive  disorders. 

Epitheliomatous  changes  in  the  mouth  are  often  diffi- 
cult to  distinguish  from  syphilis  of  the  same  region.  In 
cancer  the  process  is  slower  than  in  syphilis  ;  the  patient, 
as  a  rule,  is  older;  the  pain  is  commonly  greater;  the 
floor  of  the  resulting  ulcer  is  more  florid ;  the  lesion  in 
advanced  cases  is  larger  and  bulkier ;  in  less  advanced 
cases  there  is  a  decided  tendency  to  assume  a  verrucous 
or  fungiform  aspect ;  the  edges  of  the  ulcerated  patch 
are  everted  ;  and  the  disturbance  of  function  is  decidedly 
greater.  In  any  advanced  case  the  degree  of  cachexia 
produced  is  practically  the  same  in  the  two  affections. 

In  tuberculosis  of  the  mouth  the  lesions  are  slow  of 
evolution,  are  usually  at  first  superficial,  and  are  not 
often  limited  to  the  tongue;  the  induration  is  slight ;  the 
ulceration  is  superficial  and  is  studded  with  puncta  of 
caseous  degeneration;  and  systemic  sympathy  is  marked. 
In  all  these  diseases  glandular  enlargement  may  accom- 
pany the  mouth-lesions,  but  in  carcinoma  the  adenopathy 
of  typical  cases  is  more  constant ;  it  is  less  frequently 
noted  in  tuberculosis ;  and  in  syphilis  it  chiefly  compli- 
cates chancre  of  this  region. 

Pemphigus  vegetans  and  other  forms  of  pemphigus  and 
herpes  in  many  cases  exhibit  mouth-symptoms.  The 
mucous  membrane  of  the  mouth  is  then  usually  raw, 
red  macules  representing  the  floors  of  bullae  whose 
roof-wall  has  been  ruptured.  In  these  patients  there 
are  pain,  exquisite  sensitiveness  of  the  mouth,  and  in  bad 
cases  extreme  dysphagia ;  but  the  presence  of  bullous 
lesions  elsewhere,  the  temperature  record  of  the  patient, 
and  the  relative  acuity  of  symptoms  are  all  significant. 

Pathology. — Anatomical  study  of  sections  of  tissues 
in  most  of  the  complications  described  above  indicates 
that  the  inflammatory,  hyperplastic,  sclerous,  gumma- 
tous, and  degenerative  processes  in  the  mucous  and  sub- 
mucous tissues  are  in  all  respects  analogous  to  those 
recognized  in  the  skin  and  in  the  subcutaneous  tissues. 

10 


146      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

Small-celled  infiltration,  interstitial  hyperplasia,  epider- 
mal hypertrophy,  elongation  and  thickening  of  the 
papillae  of  the  corium,  endarteritis,  and  increase  in  the 
number  of  rete-cells,  often  with  smaller  cells  within  the 
limits  of  the  original  protoplasmic  envelope,  are  to  be 
recognized  in  most  processes.  The  presence  of  giant- 
cells  in  numbers,  as  well  as  of  bacilli,  distinguishes 
tuberculous  disorders  of  the  mouth ;  while  nests  of 
cells  in  the  corium  are  characteristic  of  the  epithelio- 
matous  changes  to  be  recognized  as  complications  of 
leucoplasic  patches. 

Syphilis  of  the  Respiratory  Tract. 

Syphilis  of  the  Nasal  Passages. — The  frequency  of 
involvement  of  the  nose  and  the  nasal  passages  in 
syphilis  is  due  to  the  exposure  of  these  regions  in  so 
many  cases  to  climatic  and  other  influences,  as  well  as 
to  the  anatomical  peculiarities  of  the  parts. 

Chancres  within  the  borders  of  the  nares  are  exceed- 
ingly rare.  An  indurated  lesion  following,  after  a 
proper  interval,  the  employment  of  instruments  for  the 
treatment  or  observation  of  any  disorder  of  this  region, 
if  accompanied  by  enlargement  and  induration  of  the 
neighboring  glands,  should  be  regarded  as  highly  suspi- 
cious. In  the  early  periods  of  syphilis  the  more  com- 
mon affections  of  the  nose  are  acute  and  chronic  rhin- 
itis, macular  and  mucous  patches,  and  circumscribed 
and  diffuse  gummatous  infiltration  of  tissue.  In  these 
cases  the  chief  symptoms  are  local  thickenings,  a  sero- 
purulent  discharge  from  the  nares,  and  sensations  of 
pain  and  fulness  of  the  part.  Gummatous  changes  may 
occur  in  any  portion  of  the  nasal  cavity,  beginning  with 
the  mucous  and  submucous  tissue,  and  spreading  thence, 
often  with  destructive  violence,  to  periosteum  and  bone. 
So  delicate  are  the  osseous  and  other  structures  of  this 
region  that  their  involvement  ma)'  be  followed  by  de- 
generative results  in  an  incredibly  brief  time.  A  patient 
complaining  of  nasal  symptoms  may  even  in  the  course 


SYPHILIS   OF  THE   RESPIRATORY  TRACT.        1 47 

of  a  few  days  suffer  a  perforation  of  the  septum  or  ex- 
hibit bony  sequestra  exfoliated  and  thrown  off  in  a  fetid 
discharge.  At  times  the  turbinated  bodies  enlarge  and 
exhibit  traces  of  fibroid  degeneration.  The  term  ozmia 
was  formerly  given  to  the  catarrhal  symptoms  common 
to  these  patients,  a  disgusting  odor  being  imparted  to 
the  breath  by  the  destructive  changes  going  on  in  peri- 
osteum and  bone,  accompanied  by  discharge  of  a  puru- 
lent, hemorrhagic,  or  serous  fluid  often  mingled  with 
detritus  of  bone.  The  highly  offensive  odor  of  this 
secretion  is  often  as  disagreeable  to  the  patient  as  to 
those  with  whom  there  is  personal  contact.  As  a  result 
of  the  several  changes  indicated,  the  bridge  of  the  nose 
may  be  destroyed,  producing  thus  a  saddle-shaped  flat- 
tening, with  at  times  a  tilting  upward  of  its  tip — a 
deformity  as  characteristic  of  syphilis  as  the  "  parrot's- 
beak  "  shape  and  the  subsequent  destruction  of  the  tip 
are  peculiar  to  lupus  of  the  same  organ.  It  is  by 
these  processes  that  the  arch  of  the  palate  is  perfo- 
rated and  at  times  practically  destroyed.  Other  sequelae 
of  this  disorder  are  the  production  of  bridles  and  bands 
stretched  from  one  side  to  another  of  the  nasal  cavity ; 
the  obliteration  of  the  passages  by  cicatricial  occlusion ; 
and  in  grave  cases,  when  severe  osseous  changes  have 
taken  place,  the  extension  of  the  disease  to  the  menin- 
ges of  the  brain  with  resulting  convulsions  and  a  fatal 
issue. 

Syphilis  of  the  Pharynx. — Chancre  of  the  tonsil  has 
already  been  described,  its  erosion  being  commonly  situ- 
ated on  the  inner  face  of  the  tonsillar  mass,  which  is  then 
enlarged,  painful,  and  apt  to  be  covered  with  an  ashy- 
looking  pultaceous  slough,  the  glands  beneath  the  jaw 
suggesting  the  nature  of  the  difficulty.  The  opposite 
tonsil  often  sympathizes  with  the  disorder,  being  en- 
gorged and  at  times  eroded. 

The  posterior  wall  of  the  pharynx  is  often  the  seat  of 
circumscribed  and  diffuse  inflammatory  thickening  (due 
to  syphilis)  and  of  mucous  patches  and  gummata.  There 


I48      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

is  in  these  cases  a  very  characteristic  smearing  of  the 
fauces  with  a  tenacious  mucus,  frequent  efforts  being 
made  by  the  patient  in  hawking  to  rid  himself  of  the 
resulting  discomfort.  Fibroid  thickening  and  gumma- 
tous ulceration  are  not  rarely  encountered,  a  character- 
istic ulcer  resulting  from  these  changes  being  recognized 
as  a  circular,  well-defined  excavation,  with  clean-cut 
edges  and  sloughy  floor,  visible  chiefly  on  depression 
of  the  base  of  the  tongue.  Grave  destructive  results 
in  extreme  cases  extend  to  the  bone  and  to  the  large 
vessels  lying  near  the  pharynx  on  either  side.  Vegeta- 
tions and  verrucous  growths  are  rare  in  this  region. 

Syphilis  of  the  Larynx. — The  morbid  changes  in 
the  larynx  due  to  syphilis  occur  in  early  and  late  periods 
of  the  disease,  and  in  both  circumscribed  and  diffuse 
manifestations.  These  changes  may  result  from  others 
occurring  in  the  upper  portion  of  the  respiratory  tract 
(nares  and  pharynx],  or  they  may  develop  primarily  in 
the  larynx  itself. 

Macular  lesions  with  transient  or  persistent  erythema 
are  not  rarely  encountered  on  the  mucous  surface ;  as  a 
result,  the  submucous  tissues  may  be  involved  in  deep- 
seated  infiltration.  The  complications  are  erosions  and 
superficial  ulcers  seated  on  an  engorged  base,  or  more 
rarely  on  a  surface  not  changed  in  hue  from  the  normal, 
visible,  on  laryngoscopic  examination,  over  the  epiglottis, 
the  vocal  cords,  the  ventricular  bands,  and  other  parts. 
Symmetrical,  multiple,  shallow  ulcerations,  involving 
with  relative  acuity  several  portions  of  the  larynx  at  one 
time,  are  peculiar  to  syphilis.  In  some  cases  the  plane 
macular  surface  changes  to  one  that  is  decidedly  elevated, 
exhibiting  a  grayish  and  reddish  tint  suggestive  of 
mucous  patches  in  the  mouth,  though  it  is  to  be  observed 
that  typically  developed  mucous  patches  are  rarely  seen 
in  the  larynx,  on  account  of  its  relative  protection  from 
many  of  the  effective  causes  of  these  lesions  in  the  mouth 
and  the  nose. 

Later,  deeper  and  more  serious  accidents  to  the  lar- 


SYPHILIS   OF   THE  RESPIRATORY  TRACT.        1 49 

ynx  result  from  gummatous  changes.  The  deposit  is  in 
the  form  of  single  or  multiple,  milium-sized  nodules  or 
diffuse  infiltrations  involving  the  submucous  tissues  of 
either  the  epiglottis,  the  interarytenoid  space,  the  vocal 
cords  (particularly  their  free  border),  or  the  subglottic 
folds,  these  growths  being  sufficient  in  extreme  cases 
seriously  to  interfere  with  the  functions  of  the  larynx. 
The  mucous  envelope  of  the  gummata  may  at  first  be 
intensely  hypersemic  and  even  covered  with  a  vascular- 
ized membrane  of  a  vivid  red  color,  or  the  hue-may  be 
yellowish,  grayish,  or  even  scarcely  altered  from  that  of 
the  surrounding  part.  The  result  may  be  complete  in- 
volution without  further  change — an  occurrence  by  no 
means  rare  in  healthy  subjects  under  proper  treatment ; 
or,  exceptionally,  ulceration  may  ensue,  and  that  to  a 
degree  of  gravity  inducing  partial  destruction  of  peri- 
chondrium, cartilage,  or  bone.  At  times  fibroid  tumors 
resembling  gummata  in  external  form  spring  from  irri- 
tated patches  where  macular  lesions  or  erosions  have 
existed,  inducing  as  much  suffering  and  exposing  the 
patient  to  as  much  danger  as  other  new  growths  of  this 
region.  Again,  membranoid  bridges,  bridles,  and  bands 
stretch  from  one  side  to  another  of  the  laryngeal  cavity, 
occluding  its  lumen  and  producing  subjective  symptoms 
not  differing  from  those  resulting  from  the  presence  of 
tumors.  Verrucous  growths  also  develop  about  the  ven- 
tricular folds,  proving  formidable  by  their  interference 
with  the  movements  of  the  organ.  There  may  result 
from  any  of  these  changes  characteristic  ulcers,  single  or 
multiple,  usually  the  latter  in  late  syphilis,  with  defined 
elevated  and  hyperaemic  margins,  often  surrounded  by  a 
zone  of  inflammation,  covered  with  a  pultaceous  slough. 
These  ulcers  when  healed  leave  cicatrices  which,  as  they 
contract,  may  either  prove  harmless  or  may  draw  together 
the  walls  or  folds  of  the  larynx,  or  fasten  the  epiglottis 
to  the  tongue  or  to  the  pharyngeal  wall.  Suppuration 
of  one  or  more  recesses  of  the  organ,  deep-seated  abscess, 
ankylosis,  paralysis,  hemorrhage,  sudden  and  dangerous 


150      SYPHILIS  AND    THE   VENEREAL  DISEASES. 

oedema,  and  the  presence  of  a  necrotic  cartilage  in  the 
larynx  acting  as  a  foreign  body,  are  all  complications  of 
severe  types  of  the  disease. 

The  chief  symptoms  recognized  without  laryngo- 
scopy examination  of  the  patient  are  a  characteristically 
hoarse  and  raucous  voice,  cough,  dyspnoea,  and  cephalic 
symptoms  due  to  imperfect  aeration  of  the  blood.  These 
symptoms  vary  from  the  mildest  to  the  severest  distress, 
the  dyspnoea  in  extreme  cases  requiring  tracheotomy. 
A  middle-aged  man  with  a  voice  reduced  to  a  faint 
whisper,  full  inflation  of  the  lungs  being  effected  by 
deep  inspirations  at  long  intervals,  should  invariably  be 
studied  with  a  view  at  least,  before  all  else,  to  setting 
aside  the  diagnosis  of  syphilis. 

It  is  to  be  noted  carefully  that  while  experts  in  laryn- 
goscopy often  find  in  doubtful  cases  of  this  category 
products  of  simple  inflammmation,  and  even  foreign  par- 
ticles, choking  the  chink  of  the  larynx,  the  onset  of 
these  troubles  is  generally  to  be  ascribed  to  localized 
syphilitic  manifestations  interfering  with  the  normal 
action  of  the  glottis.  As  it  is  the  syphilitic  mouth  which 
early  and  late  acknowledges  the  unfavorable  influence 
of  tobacco,  so  the  syphilitic  larnyx  is  exposed  to  irrita- 
tion by  the  unfavorable  influences  of  dust,  smoke,  and 
an  insalubrious  atmosphere. 

Diagnosis. — In  tuberculosis  of  the  larynx  the  existence 
of  pulmonary  symptoms  of  disease,  the  general  physical 
aspect,  condition,  family  history,  and  age  of  the  patient, 
and  the  discovery  of  bacilli  in  the  sputa,  usually  suffice 
to  determine  the  nature  of  the  disorder.  With  respect 
to  age,  it  is  interesting  to  note  that  tuberculosis  of  the 
larynx  generally  occurs  at  an  earlier  period  of  life  than 
does  syphilis  of  that  organ  with  grave  complications.  In 
tuberculosis,  as  a  rule,  the  affected  membrane  is  lighter 
in  color,  the  process  is  slower,  the  ulceration  is  more 
shallow,  the  damage  in  extreme  cases  is  far  less  serious, 
the  dysphagia  and  the  constitutional  effect  are  far  more 
pronounced,  and  the   fatal   issue  is  more  probable   and 


SYPHILIS   OF  THE   RESPIRATORY  TRACT.        151 

imminent  than  is  the  case  in  syphilis.  On  the  whole,  it 
may  be  said  that  a  striking  feature  of  syphilis  of  the 
larynx  is  that  recognized  in  syphilitic  involvement  of 
many  other  organs — namely,  a  singular  toleration  on 
the  part  of  the  patient  of  even  a  serious  mutilation  or 
destruction. 

Carcinomatous,  as  distinguished  from  syphilitic,  in- 
volvement of  the  larynx  is  a  disease  of  later  life,  develops 
in  much  slower  course,  and  is  often  accompanied  by 
hemorrhage,  which  is  relatively  rare  in  syphilis. 

The  prognosis  in  the  great  majority  of  cases  is  favor- 
able. After  wellnigh  complete  aphonia  for  months  and 
even  for  years,  restoration  of  the  voice  has  been  secured. 

Syphilis  of  the  Trachea  and  the  Bronchi. — Lesions 
of  the  trachea  and  the  bronchi  due  to  syphilis  are  far 
rarer  than  those  of  the  upper  air-passages,  or,  if  occurring 
more  frequently  than  is  believed,  they  for  the  most  part 
escape  observation.  In  general,  it  may  be  said  of  syph- 
ilis of  the  air-passages  that  its  invasions  are  from  with- 
out inward,  and  in  the  matter  of  frequency  and  multi- 
plicity are  conspicuous  the  shorter  the  excursion  from 
the  lips  and  the  nares.  The  more  deeply,  however,  syph- 
ilitic lesions  spread  toward  the  bronchi  and  the  lungs, 
the  greater,  as  a  rule,  is  the  gravity. 

The  changes  noted  in  the  trachea  and  the  bronchi  are 
practically  those  studied  in  the  larynx,  with  differences 
due  to  the  changed  anatomical  situation.  The  lesions 
may  be  consecutive  to  those  occurring  in  the  larynx,  or 
they  may  be  developed  d'emblee.  Circumscribed  and 
diffuse  patches  of  inflammation,  fibroid  changes,  gum- 
mata,  erosions,  and  ulcerations  are  the  chief  lesions  in 
the  course  of  which  the  perichondrium  and  cartilages 
may  be  involved.  Membranoid  occlusion  of  the  trachea 
and  of  one  bronchus,  extreme  stenosis,  cicatricial  stric- 
ture produced  by  bridles  and  bands,  and  fistulous  sinuses 
connected  with  abscesses  of  one  or  another  region, 
usually  the  lower,  are  sequels  of  different  cases.  The 
entire  trachea  has  been  converted  into  a  contracted  and 


152      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

distorted  tube   as   a   result  of  a   slowly  spreading  ser- 
piginous ulcer. 

Syphilis  of  the  Bones. 

Periosteum  and  bone  may  be  involved  in  both  early  and 
late  syphilis,  these  complications  occurring  from  a  few- 
months  to  a  score  or  more  of  years  after  infection.  Any 
one  of  the  bones  of  the  body  may  be  attacked,  but  those 
most  frequently  involved  are  the  bones  of  the  skull  and 
the  face,  the  palate,  the  tibia,  the  sternum,  the  clavicle, 
the  ribs,  and  the  scapulae — those,  in  fact,  most  exposed 
to  the  contacts  of  exterior  agencies.  One  or  several 
bones  may  be  simultaneously  or  successively  affected ; 
rarely  there  is  symmetrical  involvement,  as  when  both 
tibise  or  radii  are  coincidently  attacked. 

Most  of  the  changes  in  these  organs  are  due  to  cir- 
cumscribed or  diffuse  gummatous  deposits  either  in  the 
periosteum,  between  it  and  the  osseous  tissue,  within  the 
bone-substance,  or  in  the  medulla.  These  gummatous 
deposits  by  pressure  upon  contiguous  structures  may 
seriously  impair  the  function  of  other  important  organs, 
as  when  the  deposits  spring  from  the  inner  tables  of  the 
skull. 

Gummata  of  periosteum  and  bone  are  circumscribed, 
commonly  multiple,  grayish  or  yellowish-gray  nodular 
masses,  occasionally  in  diffused  patches.  The  perios- 
teum is  usually  first  attacked.  In  regions  accessible 
to  the  touch,  as  over  the  anterior  face  of  the  tibia,  a 
well-defined  swelling  may  then  be  recognized,  covered 
with  normal  integument  displaying  symmetrical  tume- 
faction, though  at  times  beset  with  irregular  and  jagged 
projections.  These  tumors  vary  in  size  from  a  bean 
to  that  of  a  large  egg;  they  are  usually  tender  and 
exceedingly  painful  even  when  not  impressed  with  the 
contact  of  a  foreign  body,  the  pain  being  character- 
istically heightened  at  night  by  the  warmth  engen- 
dered beneath  the  bed-clothing.  The  nocturnal  pains 
of  periostitis  and  osteo-periostitis  are,  indeed,  so   uni- 


SYPHILIS   OF  THE  BONES.  153 

formly  aggravated  at  night  that  they  are  generally 
considered  diagnostic,  and  they  are  justly  regarded 
with  special  suspicion  in  any  case  where  syphilis  had 
not  been  before  suggested  if  they  occur  with  quotidian 
regularity.  They  vary  in  character,  being  either  boring, 
hammering,  splitting,  or  crushing.  When  intense  and 
characteristic,  the  patient  is,  as  a  rule,  wholly  unable 
to  remain  at  rest,  though  he  may  secure  transient  relief 
by  constant  motion  of  the  affected  part,  as  when  the  legs 
are  drawn  upward  and  downward  in  bed — a  series  of 
movements  highly  suggestive  of  bone-syphilis.  The 
pains  are  in  part,  without  question,  due  to  compression 
of  inflammatory  and  other  products  between  the  tense 
and  inelastic  periosteum  and  the  unyielding  mass  of  the 
osseous  tissue.  These  symptoms  may  in  some  cases  be 
of  purely  inflammatory  type,  but,  however  acute,  it  is 
probable  that  in  all  cases  the  gummatous  process  is 
chiefly  responsible  for  the  result. 

When  the  bony  tissue  actually  participates  in  this  dis- 
order, the  result  is  a  node — a  firm  and  more  or  less  sen- 
sitive tumor,  usually  smooth  and  fairly  well  defined  in 
outline,  either  globoid  or  exhibiting  a  longitudinal  eleva- 
tion like  the  "  splint "  of  a  horse,  its  length  parallel  with 
the  long  axis  of  the  limb.  The  pains  are  usually  of  the 
sort  experienced  in  periostitis.  The  course  of  the  node 
may  be  either  complete  involution,  which  usually  occurs 
under  treatment,  or  persistence  as  a  less  painful  and  ten- 
der, even  wholly  insensitive,  bony  growth,  or  degenera- 
tion by  softening,  the  tumor  breaking  at  the  centre  and 
leaving  a  typical  syphilitic  tertiary  ulcer  with  exposed 
bone  at  the  base,  eventually  healing  after  exfoliation  of 
the  sequestrum,  with  scar-tissue  implicating  both  bone 
and  integument. 

The  resulting  deformity  depends  upon  the  region 
involved  ;  that  occurring  after  destruction  of  the  bones 
of  the  nose  has  been  described  in  the  pages  devoted  to 
syphilis  of  that  organ.  The  deformity  resulting  when 
the  extremities,  the  skull,  and  the  spine  are  attacked  is 


154      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

far    less   significant   in    acquired  than   in   inherited   dis- 
ease. 

Pathology. — Minute  gummata  of  periosteum  and  bone 
are  small-celled  new  growths  tending  to  central  degene- 
ration by  breaking  up  of  their  molecular  elements  in  a 
characteristic  atrophy.  The  cells  of  the  outlying  por- 
tions are  larger,  and  often  are  in  communication  with 
a  new  growth  of  fine  vessels.  The  medullary  sub- 
stance of  the  bone  is  at  first  increased  in  thickness. 
The  term  rarefying  osteitis  has  been  given  to  that 
process  in  which,  while  the  marrow  enlarges  and  the 
enlarging  Haversian  canals  are  stuffed  with  new  cells, 
there  is  thinning  and  eventual  absorption  of  the  osse- 
ous trabeculae,  forming  thus  spaces  in  which  the  gum- 
matous deposit  is  made,  with  the  effect  of  producing  a 
weakening  of  the  actual  osseous  structure.  Either  the 
length  or  the  thickness  of  a  bone  may  be  thus  to  gross 
appearances  greatly  increased,  while  its  substance  is 
actually  reduced. 

The  term  formative  osteitis  is  given  to  that  condition 
in  which  new  bone  is  formed  during  the  metamorphic 
changes  described  above,  by  the  production  of  trabeculae 
originating  in  the  embryonal  cells  in  the  medullary  spaces, 
these  cells  commingled  with  corpuscles  from  the  orig- 
inally involved  bony  tissue.  The  new  growths  may 
develop  between  periosteum  and  bone  or  from  the  sur- 
face of  bone  denuded  of  its  covering.  In  this  way  the 
cavities  produced  may  be  filled  with  new  bony  tissue. 
In  a  more  advanced  stage  the  new  osseous  formation 
may  undergo  a  sclerotic  hardening,  the  induration  be- 
coming as  dense  as  ivory.  Condensing  osteitis,  or  ebnr- 
nation,  produces  a  new  growth  which  encroaches  upon 
the  medullary  cavity  or,  pushing  externally,  may  pro- 
duce an  annular,  node-like,  or  splint-like  appendage  to 
the  bone  involved.  These  processes  of  rarefaction,  bone- 
formation,  and  even  bone-degeneration  to  the  point  of 
production  of  a  sequestrum  through  an  ulcerative  open- 
ing, may  occur  simultaneously  in  different  parts  of  one 


SYPHILIS   OF  THE  BONES.  155 

bone  or  side  by  side,  one  lamella  thickening  while  that 
adjacent  softens.  This  multiformity  of  processes  is  a 
characteristic  feature  of  bone-syphilis. 

When  the  gummatous  process  involves  the  medulla, 
an  osteo-myelitis  may  result,  with  degeneration  and  the 
bursting  of  an  abscess  externally,  which  is  rare ;  or  a 
formative  osteitis  with  encroachment  on  the  lumen  of 
the  medulla,  the  latter  condition  being  the  more  com- 
mon sequel. 

Syphilitic  Exostoses  (Parenchymatous  exostoses; 
Epiphysary  exostoses)  are  small-sized,  flattish,  globoid, 
ovoid,  or  irregularly  shaped  new  growths  which  usually 
begin  as  periosteal  thickenings,  but  which  may  spring 
from  an  osteitis.  At  first  they  may  seem  to  be  freely 
movable  over  the  tissue  adjacent,  but  later  they  invariably 
become  fixed  in  situ.  When  resolution  occurs,  they  may 
lose  their  characteristic  smoothness  and  ivory-like  hard- 
ness, becoming  then  knobbed  and  less  tender.  If  per- 
sistent, they  may  be  the  seat  of  considerable  pain,  and 
when  implanted  on  the  inner  face  of  the  skull,  they  may 
become  the  source  of  exceedingly  dangerous  symptoms 
of  brain  syphilis. 

Diagnosis. — Bone-syphilis  in  acquired  disease  is 
usually  recognized  without  difficulty,  since  the  history 
of  the  patient  and  the  character  of  the  pains  produced 
are  suggestive.  It  is  to  be  noted,  however,  that  tempo- 
rary swellings  along  the  axes  of  the  tibiae  occur  in  ery- 
thema nodosum,  in  which  event  there  is  usually,  with 
tenderness  of  the  node-like  masses,  marked  redness  of 
the  integument  covering  the  swelling.  The  acuity  of 
symptoms  is  also  suggestively  different  from  the  slow- 
ness of  career  of  both  syphilitic,  tuberculous,  and  rheu- 
matic nodes  of  the  same  part. 

Secondary  infection  may  occur  in  both  periostitis  and 
osteitis,  and  in  such  instances  purulent  foci  result  com- 
monly in  abscess.  In  examination  of  bones  with  a  view 
to  determination  of  probable  cause  of  death,  the  exist- 
ence of  "  worm-eaten  "  cavities,  of  irregular  thickenings, 


156      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

and  of  perforations  of  entire  plates  of  bone  is  indicative 
of  syphilis. 

Syphilitic  Dactylitis  (Syphilitic  panaris  ;  "  Syphilitic 
ringer"). — This  affection,  first  described  in  a  classical 
essay  by  Dr.  Taylor  of  New  York,  requires  special 
description  on  account  of  its  characteristic  features. 

This  disorder  is  one  involving  the  articular  and  peri- 
articular tissues  of  the  digits,  more  particularly  of  the 
fingers  ;  it  occurs  in  both  inherited  and  acquired  dis- 
ease. In  a  first  variety  the  subcutaneous,  fibrous,  and 
connective  tissues  concerned  in  the  formation  of  the  joint 
are  primarily  involved,  one  or  more  phalanges  exhibit- 
ing changes,  chiefly  on  the  dorsal  aspect,  slowly  or  (more 
rarely)  rapidly,  and  with  remissions  or  continuously. 
The  process  is  essentially  a  gummatous  infiltration  of 
the  structures  concerned  in  the  articulation.  The  digit 
is  either  over-flexed  or  over-extended,  swollen,  and  cov- 
ered with  an  empurpled  integument;  its  motions  are 
impaired ;  and  distinct  crepitus  is  perceptible  on  palpa- 
tion, due  to  erosion  of  the  cartilages  composing  the 
joint.  Ankylosis,  abscess,  destruction  of  the  capsule 
and  the  entire  joint,  or  simple  impairment  of  the  function 
of  the  articulation,  with  repair,  may  ensue. 

In  a  second  form  the  process  is  first  instituted  in  the 
osseous,  periosteal,  or  medullary  structures,  which 
become  the  seat  of  gummatous  changes  resulting  in 
thickening  of  the  two  involved  parts.  The  process 
may  result,  as  shown  above,  in  either  rarefying,  forma- 
tive, or  eburnating  osteitis,  so  that  the  digit  may  be 
increased  or  decreased  in  size,  or  become  softish  and 
cheesy  when  handled,  or  as  firm  as  ivory.  Ulceration 
and  abscess  bursting  through  the  stretched  and  empur- 
pled skin  may  lead  to  the  formation  of  fistulous  tracts 
communicating  with  bone  that  is  either  carious  or  in 
process  of  slow  repair.  An  oval,  symmetrical  tumor 
limited  to  a  single  phalanx  of  one  or  more  digital  or 
metacarpal  bones,  crepitating  under  firm  pressure  and 
painful  and  tender,  is  wellnigh  characteristic  of  syphilis. 


SYPHILIS   OF  THE  LARGER  JOINTS.  1 57 

The  atrophy  of  a  proximal  or  middle  phalanx  as  a  result 
of  the  processes  here  described,  whereby  a  distal  is  made 
to  fall  upon  a  proximal  phalanx,  or  the  distal  and  middle 
phalanges  upon  the  adjacent  metacarpal  bone,  is  highly 
suggestive  of  the  same  specific  process. 

Care  should  be  had  to  recognize  the  distinction 
between  these  deformities  and  those  due  to  tubercu- 
losis, paronychia,  and  gouty  or  rheumatic  affections  of 
the  digits.  Lepra,  the  "  melanotic  whitlow  "  of  Hutch- 
inson, and  the  lesions  of  syringomyelia  are  all  to  be  dif- 
ferentiated. 

Syphilis  of  the  Larger  Joints. 

Pains  in  the  joints  as  well  as  in  the  bones  and  the 
muscles  are  not  rare  in  early  syphilis.  These  sensations 
do  not  necessarily  imply  the  existence  of  a  localized 
lesion  of  these  organs,  but  they  often  point  to  neuralgic 
conditions  due  to  the  circulation  of  intoxicated  blood. 
At  times,  without  doubt,  they  are  due  to  the  action  of 
mercury  administered  for  the  relief  of  that  intoxication 
in  persons  peculiarly  subject  to  the  action  of  the  metal. 

Synovitis  and  arthritis  in  syphilis  ("  syphilitic  white 
swelling")  may  involve  one  or  several  of  the  larger 
joints  simultaneously,  in  which  case  the  symptoms  per 
se  are  scarcely  to  be  differentiated  from  the  same  symp- 
toms in  the  subjects  of  other  diseases.  The  articulations 
are  tumid,  tender,  painful,  and  hot  to  the  touch,  with 
limitations  in  flexion  and  extension,  and  evident  fluctua- 
tion when  synovium  is  effused  in  a  fluid  form.  Patients 
thus  affected  may  exhibit  pyrexic  symptoms ;  rarely 
have  they  been  in  good  health  prior  to  the  date  of  syphi- 
litic infection.  As  a  rule,  when  examined  they  are  pallid 
and  weak.  The  termination  of  the  arthritic  complication 
may  be  by  resolution  without  sequelae,  by  ankylosis,  or 
by  destruction  of  important  structures  in  and  about  the 
articulation  affected. 

Pathology. — The  synovial  membrane  is  usually  in 
these  cases  the  seat  of  gummatous  infiltration,  with  well- 


158      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

marked  tufts  springing  from  its  surface;  or  the  sub- 
synovial  structures,  the  ligaments,  the  capsule  of  the 
joint,  the  cartilage,  and  the  subchondroid  tissue  may  be 
involved,  with  the  result  of  producing  eventually  thick- 
ening, degeneration,  or  the  bursting  of  an  abscess  exter- 
nally, and  the  formation  of  sinuses  connecting  with  the 
joint-cavity. 

The  diagnosis  of  syphilitic  arthritis  is  made  chiefly 
by  consideration  of  other  symptoms  of  the  disease  usually 
present,  as  well  as  by  the  history  of  the  patient.  Stru- 
mous, tuberculous,  and  other  systemic  affections  exhib- 
iting arthritic  symptoms  may  in  general  be  recognized 
by  the  earlier  age  of  the  patient.  In  syphilis  the  knee 
and  the  sterno-clavicular  and  scapuloclavicular  joints 
are  chiefly  involved.  The  hip  is  very  rarely  attacked 
in  syphilis.  Adult  male  patients  are  liable  to  display 
these  symptoms  usually  from  two  to  four  years  after 
infection. 

Syphilis  of  the  Burs^. 

The  bursae  may  be  acutely  inflamed,  with  symptoms 
of  tumefaction,  tenderness,  pain,  sensations  of  heat,  and 
redness  or  an  unchanged  color  of  the  skin  over  the 
part ;  but  this  complication  is  rare.  More  often  an  in- 
sidiously deposited  gummatous  material  accumulates 
within  or  about  the  bursa.  In  practice  the  distinction 
is  often  well  made  between  a  gummatous  degeneration 
of  the  tissue  about  a  large  bursa,  later  involving  and 
opening  into  the  latter,  and  a  specific  primary  involve- 
ment of  the  sac.  The  subsequent  career  of  the  lesion, 
whether  after  resolution  or  after  degeneration,  is  practi- 
cally that  of  the  same  process  in  the  skin.  When  the 
prepatellar  bursa  or  that  over  the  tuberosity  of  the  tibia 
is  implicated,  the  disorder  has  been  termed  "  tertiary 
syphilitic  housemaid's  knee." 


syphilis  of  the  muscles.  1 59 

Syphilis  of  the  Tendons  and  the  Tendinous 
Sheaths. 

The  tendons  and  the  tendinous  sheaths  may  be  acutely 
or  slowly  involved  in  gummatous  processes  beginning 
either  in  the  teno-synovial  sheath  or  in  any  of  the  con- 
tiguous parts.  The  process  is  usually  accompanied  by 
pain  and  disturbance  of  function.  In  these  cases  firm, 
elastic,  and  more  or  less  fluctuating  swellings  covered 
with  a  normal  or  engorged  integument  are  ranged  along 
the  lines  of  the  tendons,  and  do  not  extend  beyond  the 
limits  thus  defined.  They  are  due  to  effusion  in  the 
-tendinous  sheaths,  and  their  formation  may  be  preceded 
by  a  painful  hyperaemia.  The  issue,  even  after  extensive 
hydrops,  is  usually  complete  resolution,  but  more  or  less 
persistent  thickening,  ulceration,  or  agglutination  of  the 
tendon  to  its  sheath  may  follow.  Gummy  tumors  also 
may  form  either  in  the  body  or  near  the  insertion  of 
tendons,  the  newly-formed  tissue  here  or  elsewhere  disap- 
pearing later  by  resolution  or  degenerating  by  ulceration. 

Syphilis  of  the  Aponeuroses. 

The  aponeuroses  may  be  involved  in  the  processes 
of  syphilis,  usually  by  extension  of  gummatous  infiltra- 
tions from  adjacent  tissues.  The  significance  of  this 
lies  chiefly  in  the  consequences  to  the  structures  with 
which  such  aponeuroses  are  in  anatomical  connection. 

Syphilis  of  the  Muscles. 

Myositis  occurs  in  syphilitic  subjects  in  differing 
forms.  It  has  been  supposed  that  the  muscular  pains 
experienced  soon  after  infection  in  any  subject  proceed 
from  an  "  irritative  myositis,"  but,  as  has  been  shown,  it 
is  probable  that  these  pains  are  due  either  to  the  nerves 
supplying  the  muscles,  which  acknowledge  the  presence 
of  a  special  toxine  without  change  in  the  tissues,  or  to  the 
special  sensitiveness  of  some  patients  to  the  early  action 
of  mercury  administered  with  a  view  to  the  relief  of  the 


l6o      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

disease.  In  any  event,  the  muscle-lesions  in  such  cases 
are  not  yet  demonstrated. 

In  chronic  interstitial  forms  of  myositis  it  has  been 
demonstrated  with  sufficient  clearness  that  a  gummatous 
infiltration,  diffused  or  in  distinct  foci,  may  involve  the 
muscle-bundles,  resulting  in  compression  of  the  latter, 
with  consequent  pain,  distortion,  and  even  permanent 
contracture.  The  ultimate  issue  as  regards  the  infiltrate 
is  either  fatty  degeneration  and  coagulation-necrosis, 
ulceration  and  fistulous  connection  with  the  outer  in- 
tegument, or  complete  resolution  with  restoration  of 
function. 

Progressive  ossifying  myositis  is  a  rare  complication 
of  formative  and  eburnating  osteitis,  though  it  is  claimed 
to  have  resulted  from  changes  in  the  central  nervous 
system. 

Atrophy  of  muscles  in  syphilitic  subjects,  especially  in 
those  who  have  been  its  victims  for  years,  is  more  com- 
mon than  is  usually  believed  to  be  the  case.  It  may  re- 
sult from  (a)  gummatous  involvement  of  the  nerves,  the 
ganglia,  or  the  tissues  about  the  same ;  (b)  from  gumma- 
tous deposits  in  the  muscles  themselves ;  or  (c)  from  dis- 
use of  the  limbs  and  the  body  in  syphilitic  subjects  as  a 
result  of  disease  of  other  organs  involving  long-con- 
tinued decubitus,  or  of  life  in  a  wheeled-  chair  (grave 
ulceration  of  feet  and  legs,  severe  ulceration  opening 
into  the  knee-joint,  etc.). 

Syphilis  of   the  Heart. 

Pericarditis  is  a  rare  complication  of  syphilis ;  it 
results  from  gummatous  deposits  in  the  fibrous  tissue 
or  from  implication  of  the  pericardia  by  the  extension 
thither  of  a  degenerative  process  originating  in  neigh- 
boring organs. 

Gummata  in  the  form  of  distinct  yellowish  circum- 
scribed nodules  may  be  found  post-mortem  in  the  septa 
and  the  substance  of  the  heart,  usually  accompanied 
by  hypertrophy  and  thrombus.     On  section  these  gum- 


SYPHILIS   OF   THE  HEART.  l6l 

mata  are  seen  to  be  non-vascular  and  composed  of  a 
capsule  of  connective  tissue  within  which  lies  centrally  a 
sclerotic  mass.  In  the  tissue  where  these  gummata  have 
been  implanted  the  muscles  are  replaced  by  fibrous  bands. 

The  fibrous  myocarditis  of  syphilis  is  due,  according 
to  Councilman,  to  an  encroaching  endocarditis  affecting 
the  coronary  arteries,  as  a  consequence  of  which  the 
heart-muscles  undergo  various  degenerations.  The  sub- 
endothelial  tissue  of  the  heart  may  be  responsible  for 
changes  which  have  been  described  as  a  syphilitic  endo- 
carditis, in  which  whitish  nodules  have  been  detected 
along  the  free  edges  of  the  valves,  with  thickening 
and  induration  of  the  pericardium,  shortening  of  the 
chordae,  and  thrombi  of  the  free  surface. 

Aneurysm  of  the  Heart. — In  a  few  instances  saccular 
dilatations  of  the  ventricular  space,  with  walls  indurated, 
in  part  and  in  part  thinned,  have  been  recognized  post- 
mortem in  the  ventricles,  one  or  several  of  such  dilata- 
tions being  visible  in  a  single  subject. 

Among  all  the  lesions  recognized  after  death  in  the 
heart  and  the  vessels  of  the  subjects  of  undoubted  syph- 
ilis, it  is  difficult  to  determine  which  should  be  de- 
scribed as  directly  due  to  that  disease,  and  which  to 
the  indirect  results  of  cachexia  and  to  the  presence 
of  a  chemical  toxine  engendered  by  the  mutual  play  of 
micro-organism  and  invaded  tissue.  Without  question, 
some  of  the  conditions  described  above  are  the  indirect 
results  of  specific  infection,  the  direct  attack  of  which 
has  been  pursued  along  different  lines. 

The  symptoms  of  many  of  the  lesions  suggested 
above  are  not  readily  differentiated  from  those  occur- 
ring in  non-syphilitic  subjects.  They  are  for  the  most 
part  betrayed  in  disturbances  of  respiration,  praecordial 
distress,  angina,  asthma,  palpitation  of  the  heart,  and 
other  symptoms  accompanied  by  nocturnal  aggravation, 
such  as  headache,  dizziness,  angina,  and  visual  disturb- 
ances. The  syphilitic  lesions  of  the  heart  are  apt  to 
occur  in  middle  or  late  life,  if  at  all,  when  the  symptoms 

11 


1 62      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

of  a  gouty  tendency  with  renal  complications  are  not 
rarely  present.  In  the  simpler  syphilitic  affections  of  the 
heart  the  distress  is  usually  paroxysmal,  and  the  general 
condition  of  the  patient  is  one  of  weakness  occurring 
simultaneously  with  the  cardiac  disturbance.  Complete 
relief  may  ensue  under  treatment,  but  fatal  results  are 
recorded. 

Syphilis  of  the  Blood-vessels. 

Arterio -sclerosis. — There  are  two  forms  of  disease  to 
which  the  title  arteriosclerosis  has  been  given.  These 
are  the  diffuse  and  the  circumscribed  (or  nodular) 
forms.  Both  are  due  to  a  primary  fatty  metamor- 
phosis of  the  muscular  walls,  with  consequent  dilata- 
tion of  the  lumen  and  compensatory  increase  of  the 
intima  of  the  vessel,  which,  as  also  the  muscular  over- 
growth, may  subsequently  undergo  hyaline  or  atherom- 
atous degeneration.  From  these  changes  aneurysmal 
pouches  may  form  ;  and  the  modern  view  that  all  aneur- 
ysms not  originating  in  trauma  should  be  suspected  to 
be  syphilitic,  is  in  part  due  to  the  fact  that  iodide  of 
potassium  has  proved  of  value  in  so  many  instances. 

Endarteritis  Obliterans. — In  this  special  affection 
there  is  proliferation  on  the  part  of  the  endothelium 
of  the  vessel,  resulting  in  a  thickening  which  eventually 
involves  all  the  tunics  of  the  vessel,  and  in  an  encroach- 
ment upon  its  calibre  tending  to  obliteration.  The  pro- 
cess is  differentiated  from  the  arterio-sclerosis  described 
above  chiefly  in  the  production  of  a  neoplastic  as  dis- 
tinguished from  the  purely  hypertrophic  thickening  of 
arterio-sclerosis.  A  gummatous  periarteritis  in  which 
the  adventitia  and  the  media  are  involved  has  also  been 
observed  in  both  the  circumscribed  and  diffuse  forms. 
The  hyaline  and  amyloid  degenerations  of  the  small- 
sized  arteries,  as  well  as  the  primary  changes  described 
above,  are  encountered  as  well  in  non-syphilitic  disease. 
Here,  as  in  syphilis  of  the  skin,  the  mode  of  involve- 
ment rather  than  the  lesion  is  characteristic  of  syphilis. 


SYPHILIS   OF  THE   LUNGS.  1 63 

It  is  the  recognition  of  several  necrotic  points  with  re- 
striction of  the  lumen  of  the  vessel  by  thickening  of  the 
intima  that  suggests  the  nature  of  the  process  in  any 
given  case. 

Aneurysm. — Syphilis  may  be  the  etiological  factor  of 
importance  in  all  cases  of  aneurysm  not  directly  trace- 
able to  traumatism.  The  aorta  and  the  cerebral,  radial, 
temporal,  and  popliteal  arteries  are  the  most  frequently 
attacked,  and  in  a  very  considerable  proportion  of  cases 
syphilis  may  be  demonstrated  to  be  the  chief  factor  in 
the  production  of  the  symptoms.  It  is  probable  that 
in  most  instances  the  first  changes  are  of  the  nature  of 
an  arterio-sclerosis,  whether  diffuse  or  circumscribed ; 
and  when  the  weakening  of  vessel  or  heart-wall  has 
once  been  determined  the  influence  of  alcoholism,  of 
gout,  or  of  the  several  auto-intoxications  and  chemical 
intoxications  of  the  system — often,  indeed,  with  an  ex- 
citing cause  in  the  way  of  over-strain — leads  to  the  most 
serious  results.  All  such  patients  should  be  subjected 
to  a  very  careful  urinary  examination.  By  the  best 
methods  of  modern  treatment  even  the  most  unprom- 
ising cases  may  be  improved. 

Syphilis  of  the  Lungs. 

The  great  difficulty  in  discriminating  between  gum- 
mata  of  the  lung  and  tubercles  of  the  same  organ  has 
up  to  the  present  obscured  the  characteristic  features 
of  syphilitic  disease.  Gummata  occur  as  firm,  often 
quite  dense,  whitish,  grayish,  or  reddish-gray  nodules, 
set  in  consolidated  lung-tissue,  and  varying  in  size  from 
a  split-pea  to  that  of  a  small  egg.  They  are  built  up  of 
granulation-tissue  ;  they  degenerate  rapidly  by  caseation, 
fatty  metamorphosis,  and  central  necrosis.  Fibrous  tra- 
becular pass  from  the  outer  envelope  of  the  mass  toward 
its  centre,  as  if  to  produce  lobulation.  These  lesions 
are  found  in  the  posterior  and  lower  lobes  of  the  lung 
oftener  than  in  its  apices,  furnishing  thus  a  valuable 
diagnostic  difference  between  syphilis  of  the  lung  and 


164      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

the  apical  disorders  of  early  pulmonary  tuberculosis 
{SpitzenkatarrJi).  Diffuse  infiltration  of  gummatous  ma- 
terial in  the  lungs  is  characterized  by  the  consolidation 
of  a  smaller  or  larger  area,  as  the  result  of  accumula- 
tion in  the  alveoli  of  an  epithelio-fibrinous  exudate,  or 
from  a  new  growth  of  connective  tissue.  On  section 
the  lung  closely  resembles  the  condition  seen  in  simple 
pneumonia,  its  substance  being  firm  and  in  color  grayish 
and  reddish.  Under  the  microscope  the  connective  tis- 
sue is  seen  to  extend  from  the  blood-vessels  into  the 
thickened  alveolar  parietes,  almost  obliterating  the  alve- 
oli or  changing  them  into  narrow  clefts  with  epithelial 
linings.  The  absence  of  leucocytes  is  conspicuous. 
Councilman,  who  amply  illustrated  this  subject,  describes 
this  condition  as  a  "  true  syphilitic  pneumonia." 

Gummatous  Fibrosis  of  the  Lung1. — In  this  condi- 
tion the  tissue  about  the  bronchi  and  the  arteries  under- 
goes a  fibrinous  metamorphosis  to  the  point  of  produc- 
tion of  thick,  cord-like  radiations  spreading  from  the 
root  of  the  lung  toward  the  pleura,  inducing  later,  by 
contracture,  both  emphysematous  and  atrophic  states 
of  the  constricted  pulmonary  tissue.  Along  these 
fibrous  bands  are  set  gummata  of  usual  type  which  may 
degenerate  by  ulceration.  Irregularly  alternating  points 
of  constriction  and  dilatation  of  the  bronchi  produce  the 
symptoms  of  bronchitis  of  non-specific  type — evolution 
of  pus-cells  with  thickening  and  erosions  of  the  mucous 
surface. 

Ulceration  in  the  lungs,  with  the  consecutive  forma- 
tion of  cavities,  as  in  pulmonary  tuberculosis,  has  been 
both  affirmed  and  denied  as  of  occurrence  in  syphilis. 
There  is  good  reason,  however,  to  believe  trustworthy 
the  recorded  cases  in  which  cavities  have  been  found, 
communicating  or  not  with  bronchi,  surrounded  by  firm 
cicatricial  tissue,  and  associated  with  other  symptoms  of 
that  disease  in  unquestioned  subjects  of  syphilis. 

Diagnosis. — The  discovery  of  tubercle  bacilli  in  any 
case  is  of  the  greatest  value  in  establishing  a  distinction 


SYPHILIS   OF  THE   G ASTRO-INTESTINAL    TRACT.     1 65 

between  syphilis  and  tuberculosis  of  the  lungs.  The 
physical  signs  of  consolidation,  dyspnoea,  and  cough  are 
in  the  two  usually  similar.  We  have  seen  severe  hemor- 
rhage, even  to  the  point  of  fainting,  with  perfect  re- 
covery. The  chief  important  points  are  the  localization 
of  the  disease  in  syphilis  (as  already  shown) ;  an  ap- 
parent limitation  of  all  symptoms,  in  certain  cases,  to 
the  chest ;  the  remarkably  good  thoracic  development 
and  general  physique  of  many  subjects  of  the  disease ; 
the  frequent  absence  of  fever ;  and  the  marked  dyspncea 
of  some  of  the  affected. 

Syphilis  of  the  Gastrointestinal  Tract. 

Syphilitic  lesions  of  the  oesophagus  are  known  only 
in  the  report  of  a  few  isolated  cases,  upon  which  some 
doubt  rests  in  consequence  of  their  great  rarity.  Of 
cases  in  which  the  stomach  is  reported  to  have  been 
involved,  though  the  recorded  instances  are  somewhat 
more  numerous  than  of  oesophageal  invasion,  but  little 
is  known  of  any  characteristic  symptoms.  Gummatous 
infiltration  of  the  mucous  and  submucous  tissue  is 
supposed  to  be  responsible  for  areas  of  definite  out- 
line where  at  one  or  more  points  thickening  and  sub- 
sequent ulceration  have  occurred.  Syphilis  of  the  in- 
testinal canal  is  rarely  encountered  save  in  the  ano- 
rectal pouch.  Its  lesions  are  due  to  gummatous  deposits, 
either  diffuse  or  in  localized  points,  the  latter  often  cor- 
responding with  the  sites  of  the  agminate  glands.  The 
results  are  seen  in  fibrous  thickenings  and  dense  infil- 
trations, with  ulceration  at  one  or  several  points.  Often 
there  is  coincident  peritoneal  adhesion  and  serous  effu- 
sion. 

Syphilis  of  the  Liver. — Gummata  are  not  rarely  found 
in  the  liver  of  the  subjects  of  syphilis,  where  they  appear 
as  few  or  numerous  grayish-red  and  grayish-yellow 
nodules  lying  near  the  capsule  or  deeply  set  in  the  sub- 
stance of  the  organ.  When  lying  near  the  superficies 
they  usually  induce  contracture  of  the  hepatic  capsule, 


1 66      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

which  is  also  often  thickened  and  attached  to  the 
adjacent  organs.  The  nodules  are  composed  of  con- 
nective tissue,  which  undergoes  a  metamorphosis  into 
dense  cicatricial  bands  appearing,  when  they  are  fully- 
developed,  to  divide  the  hepatic  mass  into  lobules. 
Centrally  the  nodules  undergo  softening  and  necrosis, 
due  to  obliteration  of  the  vessels  which  supply  them. 
Most  observers  agree  with  Virchow,  that  there  is  also  a 
fibrosis  affecting  the  syphilitic  liver,  not  due  to  gum- 
matous deposits.  In  these  cases  fibrous  bands  stretch 
from  the  capsule  in  many  directions,  compressing  the 
hepatic  substance  between  the  divisions  thus  artificially 
produced,  which  are  further  intersected  by  lesser  stria- 
tions  of  fibres  passing  from  the  larger  bands.  The  effect 
is  very  like  the  shrunken  condition  of  the  gland  occur- 
ring in  cirrhosis.  As  a  sequence  of  this  and  also  of  the 
other  changes  noted  above,  amyloid  degeneration  both 
of  the  walls  of  the  hepatic  vessels  and  of  the  liver-cells 
themselves  may  occur.  Calcareous  metamorphosis  is 
rarely  seen,  and  ulceration  is  of  rare  occurrence.  We 
have  noted  a  single  case  only  in  which  an  adult  within 
the  first  year  of  infection  died  apparently  as  the  sole 
consequence  of  syphilis  of  the  liver.  This  organ  was 
stuffed  with  gummata  to  an  extent  interfering  seriously 
with  the  performance  of  its  function. 

During  life  it  is  rare  that  any  symptoms  are  displayed 
sufficiently  distinct  to  point  unmistakably  to  hepatic  in- 
volvement. Icterus  is  by  no  means  rare  in  syphilis, 
especially  in  its  early  months ;  there  can  be  little  ques- 
tion, however,  but  that  the  symptoms  may  be  wholly  due 
to  functional  derangement  of  the  liver.  Pain  and  tender- 
ness in  the  hepatic  region,  enlargement  of  the  liver,  and 
ascites  may  or  may  not  be  present.  There  is  frequent 
coexistence  of  albuminuria. 

The  jaundice  of  late  syphilis  due  to  hepatic  complica- 
tions is  distinguishable  at  times  by  special  features  from 
the  evanescent  and  probably  functional  disorder  of  the 
same  type  in  early  periods  after  infection.     The  patient 


SYPHILIS   OF  THE   RECTUM  AND    THE  ANUS.    1 67 

has  usually  the. appearance  of  strongly  marked  cachexia; 
he  is  thin,  shrunken,  weak,  and  livid,  or  bloated  and 
flabby.  The  color  of  the  skin  is  a  deep  yellowish-brown 
as  distinguished  from  the  decidedly  lighter  yellow  hue  of 
the  jaundice  due  to  functional  disturbance  of  the  bile- 
secretion.  There  is  usually  severe  headache,  and  often 
albuminuria. 

Acute  yellow  atrophy  of  the  liver  is  reported  as  of 
occurrence  in  a  few  cases  as  a  result  of  syphilitic  infec- 
tion. The  symptoms  were  scarcely  to  be  differentiated 
from  those  of  the  non-specific  changes  in  the  same  organ. 

There  are  no  signs  absolutely  diagnostic  of  hepatic 
disease  in  syphilis. 

Syphilis  of  the  spleen  and  of  the  pancreas  is  ex- 
ceedingly rare.  When  unmistakably  involved,  the  spleen 
may  be  large  and  soft,  as  in  non-syphilitic  affections, 
or  enlarged  and  indurated  from  fibrosis,  or  affected 
with  diffuse,  yet  more  rarely  circumscribed,  gummatous 
deposit.  As  usual  in  splenic  enlargements,  when  volu- 
minous as  a  consequence  of  syphilis,  the  organ  is  usu- 
ally many  times  its  normal  size. 

When  the  pancreas  is  attacked,  the  lesions  of  syphilis 
are  usually  found  in  and  about  the  head  of  the  gland, 
which,  like  the  spleen,  may  be  either  enlarged  or  dense 
and  contracted.  In  the  latter  event  the  acini  are  firmly 
compressed,  as  in  the  case  of  the  hepatic  cells  of  the 
liver,  by  an  interstitial  overgrowth,  corresponding  with 
the  condition  of  fibrosis  found  in  the  spleen.  Circum- 
scribed gummata  of  this  gland  are  rare,  but  they  have 
been  noted  in  both  large  and  miliary-sized  nodules. 

Gummatous  changes  of  the  suprarenal  glands  have 
been  reported  in  a  few  instances.  The  affection  may  be 
said,  however,  in  consequence  of  its  great  rarity,  to  be  a 
pathological  curiosity. 

Syphilis  op  the  Rectum  and  the  Anus. 
Chancres  of  the  anal  region  are  apt  to  be  ignored  in 
consequence  of  the  fact  that  physician  and  patient  do 


1 68      SYPHILIS  AXD    THE   VENEREAL   DISEASES. 

not  usually  suspect  the  nature  of  the  trouble.  In  our 
experience  these  lesions,  as  distinguished  from  the  soft 
chancres  of  the  anal  region  occurring  in  women,  are 
more  common  in  men,  and  result  usually  from  prac- 
tices against  nature.  These  initial  scleroses  are  often 
supposed  to  be  "  piles,"  of  which  complaint  is  usually 
made.  Split-pea-sized  and  firm  papules  are  then  visible, 
usually  one  only,  just  beyond  the  anal  verge,  and  the 
bubo  of  the  vicinity  is  distinguishable  in  the  inguinal 
region  or  elsewhere.  Other  scleroses  of  this  part  are 
erosions  and  ulcers.  The  star-shaped  ulcer  of  the  soft 
chancre  of  the  anus  is  never  imitated  by  the  syphilitic 
sclerosis,  by  reason  of  the  failure  of  auto-inoculabil- 
ity.  Chancres  within  the  verge  of  the  anus  are  rarely 
seen. 

The  early  perianal  lesions  of  systemic  syphilis  are 
usually,  and  especially  in  the  case  of  young  adults,  flat 
papules,  springing  or  not  from  macular  lesions.  These 
may  be  discrete  or  confluent,  in  the  latter  event  produ- 
cing a  perianal  zone  of  infiltration  with  a  dull  redness 
that  might  lead  the  inexpert  to  suppose  the  case  to  be 
one  of  eczema,  especially  when,  as  is  often  the  case,  the 
lesions  of  this  region  are  the  seat  of  a  considerable  pru- 
ritus. 

In  consequence  of  heat,  moisture,  and  friction,  these 
papules  have  a  uniform  tendency  to  flatten  and  to  fur- 
nish a  secretion.  In  this  way  miliary  and  (more  often) 
lenticular  papules,  condylomata,  elevated  mucous  patches 
and  mucous  plaques,  verrucous  growths,  and  other 
hypertrophic  lesions  develop  about  the  anal  orifice.  As 
a  consequence  of  their  softness  they  readily  break  down 
into  fissures  radiating  from  the  anus,  and  even  into 
formidable  ulcers.  The  secretion  they  furnish  is  com- 
monly exceedingly  foul.  Many  of  the  widely  variant 
hypertrophies  once  known  under  the  misleading  title  of 
"lupus  of  the  vulva"  (csthiomene)  are  papillomatous 
growths  about  the  anus  as  large  as  an  egg  and  larger, 
beginning  in  an  overgrowth  of  flat  moist  papules  of  this 


SYPHILIS   OF   THE    RECTUM  AND    THE   ANUS.    1 69 

region.  As  these  lesions  are  rapidly  developed,  so  in 
favorable  cases  and  with  the  best  of  treatment  they  can 
be  made  to  disappear  speedily. 

More  minute  ulcerations  occur  at  the  verge  of  the 
anus,  usually  multiple,  reddish  or  grayish  in  hue,  oval 
and  elongated,  rarely  circular,  not  very  painful,  and  dis- 
covered perhaps  by  the  physician  engaged  in  making  a 
careful  search  for  lesions.  With  reference  to  some  of 
these,  a  doubt  exists  as  to  their  exclusive  origin  from  the 
infectious  disease  present.  They  are  seen  in  persons 
who  have  never  been  infected,  and  they  are  discovered 
with  surprising  frequency,  by  practitioners  who  habitu- 
ally make  examinations  of  the  anal  region,  in  all  classes 
of  all  subjects  after  middle  life.  A  line  of  demarcation 
is  drawn  between  these  and  the  other  ulcers  of  syphilis, 
in  the  fact  that  with  exceedingly  few  exceptions  simple 
ulcers  never  produce  the  formidable  ravages  to  which 
almost  every  syphilitic  loss  of  tissue  at  times  succumbs. 
The  really  serious  destructions  of  tissue  about  the  anus 
are  produced  chiefly  by  the  chancroid. 

Tuberculous  ulcers  of  the  anal  region,  to  which  for 
a  long  period  the  title  "  tuberculosis  of  the  skin  "  was 
practically  limited,  are  wholly  different  from  the  minute 
'lesions  described  above.  The  tuberculous  losses  resem- 
ble rents  or  tears  of  the  tissue ;  they  have  sharply  cut 
walls,  deep  floors  looking  like  clefts,  and  are  as  irregu- 
larly outlined  as  if  cut  at  random.  Syphilitic  ulcers  of 
this  region  are  circular  in  outline  and  have  undermined 
walls  and  pultaceous  floors.  Multiple  tuberculous  ulcera- 
tion of  the  rectum  always  occurs  in  connection  with  other 
symptoms  of  tuberculous  disease. 

Large  ischio-rectal  abscesses,  especially  in  fleshy 
women,  often  leave  formidable  ulcers  as  sequelae  re- 
quiring surgical  treatment.  These  are  not  to  be  con- 
founded with  the  lesions  described  above. 

Gummata  of  the  Rectum.  ("  Ano-rectal  syphiloma;" 
Syphilitic  stricture  of  the  rectum). — Several  processes 
have   been    described   in    connection   with    eummatous 


170      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

changes  in  the  rectum,  and  there  have  been  given  to  the 
resulting  deformities  of  this  organ  names  which  distin- 
guish merely  different  phases  of  one  disorder.  The 
simplest  consideration  of  the  subject  is  that  which 
traces  the  career  of  a  single  process  in  these  several 
manifestations. 

Gummata  develop  in  the  rectum  as  smooth,  circum- 
scribed bodies  set  in  the  mucous  or  submucous  tissue. 
They  may  be  single,  multiple  or  exceedingly  numer- 
ous, or  diffuse  in  two  significant  directions.  In  the  one 
the  area  of  development  occupies  a  district  more  or 
less  parallel  with  the  long  axis  of  the  gut.  In  this  event 
contracture  of  the  infiltrated  tissue  does  not  involve  co- 
arctation of  the  rectal  walls.  In  the  other  case  the  gum- 
matous involvement  occurs  in  an  annular  form,  encir- 
cling the  rectal  pouch  usually  between  two  and  three 
inches  from  the  anus.  In  the  latter  event  contracture 
of  the  gummatous  mass  acts  in  the  same  manner  and 
direction  as  a  sphincter  muscle,  and  induces  coarctation 
of  the  walls  of  the  rectum.  All  the  phenomena  of 
stricture  of  the  rectum  may  result  from  this  annular 
gummatous  change  in  the  intestine,  and  the  "  ano-rectal 
syphiloma  "  of  certain  French  authors  is  thus  produced. 

The  questions  arise  whether  every  stricture  of  the 
rectum  is  consequent  upon  gummatous  changes,  and 
also  whether  every  stricture  of  the  rectum,  as  has  been 
believed,  is  due  to  syphilis. 

With  respect  to  the  first  question,  it  is  clear  that  while 
every  syphilitic  stricture  of  the  rectum  is  practically  due 
to  gummatous  infiltration  of  the  rectal  walls,  it  by  no 
means  follows  that  the  beginning  of  the  mischief  lay  in 
gummatous  change.  Early  in  the  history  of  most  cases 
there  is  a  record  of  uneasiness  at  stool  and  perhaps 
of  blood-smeared  faeces,  indicating  that  some  local 
lesions,  possibly  erosions  or  superficial  ulcers,  had  ex- 
isted before  the  more  serious  change  occurred.  The  un- 
fortunate part  of  such  histories  is  the  rarity  with  which 
the  expert  explores  the  rectal  pouch  before  gummatous 


SYPHILIS   OF  THE   RECTUM  AND    THE  ANUS.    171 

infiltration  can  be  demonstrated.  The  second  question 
can  be  dismissed  with  some  certainty,  even  in  the  face 
of  dogmatic  assertions  to  the  contrary.  Syphilis  is  the 
cause  of  the  majority  of  all  cases  of  stricture  of  the 
rectum.  But  this  serious  disorder  may  also  result  from 
the  contraction  induced  by  chancroids  of  the  same  part, 
and  it  is  probable  that  it  may  also  result  from  tubercu- 
losis and  other  changes  in  the  same  organ.  A  few  trau- 
matic cases  are  on  record. 

When  an  annular  gummatous  band  constricts  the  rec- 
tum, it  produces  a  fibrinous  change  in  the  wall  of  the 
gut,  the  contracture  of  which,  whether  there  be  or  not 
antecedent  changes  in  the  mucous  membrane,  sets  up  a 
proctitis  liable  to  result  in  such  changes.  It  has  been 
seen  that  in  certain  organs,  notably  the  liver,  an  unques- 
tioned gummatous  deposit  may  result  in  a  very  firm  and 
contractile  fibrosis.  This  is  what  happens  in  the  rectum. 
In  some  of  these  gummatous  involvements  the  fibrous 
metamorphosis  of  the  walls  of  the  rectum  is  so  com- 
pletely annular  in  its  direction  that  a  steadily  increasing 
contraction  occurs  in  the  grasp  of  the  ring,  encroaching 
more  and  more  upon  the  calibre  of  the  gut.  By  inter- 
ference with  the  excretion  of  the  intestinal  contents, 
and  by  inducing  a  catarrhal  condition  of  the  bowel  above 
the  coarctation  set  up  by  such  interference,  one  of  the 
gravest  and  most  menacing  of  the  complications  of 
syphilis  in  the  human  body  is  eventually  established. 

On  digital  exploration  the  milder  cases  suggest  to  the 
touch  that  the  mucous  surface  is  merely  thickened  ;  at 
times  both  increase  in  thickness  and  roughening  of  the 
inelastic  surface  can  be  appreciated.  Later  the  finger 
encounters  an  annular  and  sensitive  band,  dense  in  struc- 
ture, unyielding,  and  varying  with  respect  to  the  size  of 
the  usually  central  aperture  which  it  surrounds,  the 
latter  being  at  times  sufficiently  pervious  to  admit  the 
tip  or  the  entire  thickness  of  the  digit ;  or  the  gut 
may  be  so  occluded  as  to  furnish  no  perceptible  open- 
ing.    The  free  edge  of  this  strictured  portion  is  usually 


172      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

sharp  to  the  touch.  The  commonest  complications 
are  papillomatous  and  other  growths,  with  ulceration 
of  the  mucous  surface  of  the  rectum  and  dilatation 
of  the  pouch  above  the  stricture.  Very  constant  of 
occurrence  are  peculiar  lobulated  or  tongue-like  growths 
about  the  anus  {languettes),  in  many  cases  wholly  ex- 
ternal to  the  gut,  usually  numerous,  and  due  to  con- 
gestion of  the  parts  below  the  site  of  constriction. 
These  growths  are  almost  pathognomonic  of  the  disease. 
Hemorrhage,  prolapse  of  the  fundus  of  the  bladder,  and 
constant  dribbling  of  urine  are  also  symptoms  of  ex- 
treme distress  in  women,  that  sex  furnishing  by  far  the 
largest  number  of  all  patients.  There  is  usually  a  stead- 
ily increasing  sense  of  weight  in  the  pelvis,  and  after 
ulceration  painful  defecation,  with  either  flattened  stools 
or  liquid  evacuations,  the  sole  relief  of  the  intestinal  ob- 
struction occurring  as  the  result  of  a  diarrhoea.  In 
extreme  cases  the  rectum  is  transformed  into  a  thick- 
ened cylinder  with  a  tortuous  and  contracted  interior 
canal,  encroached  upon  throughout  its  length  by  con- 
tractions, irregular  nodules,  bands,  and  knobbed  masses. 

The  diagnosis  is  to  be  made  between  the  lesions  of 
the  rectum  produced  by  syphilis,  chancroid,  carcinoma, 
and  tuberculosis.  For  the  most  part,  the  history  of  the 
patient  and  microscopical  examination  are  required  in 
order  to  ascertain  the  facts. 

"  Proliferating  syphilitic  rectitis  "  (rectite  proliferante 
sypliilitiqite  of  the  French)  is  a  term  used  to  designate 
the  form  of  rectal  disease  in  syphilis  characterized  by 
unusual  hypertrophic  growths  in  the  form  of  vegetations 
and  nodules  on  the  rectal  membrane. 

Syphilis  of  the  Genito-urinary  Organs. 

In  Men. — The  penis  is  the  frequent  seat  of  the 
initial  scleroses  of  syphilis,  of  all  consecutive  lesions  of 
the  same  disease,  and  of  gummata  which  ulcerate  and  at 
times  produce  extensive  ravages  of  both  cutaneous  and 
subcutaneous   tissue.     These    lesions    have     heretofore 


SYPHILIS   OF  THE    GENITO-URINARY  ORGANS.    1 73 

been  described  in  these  pages,  as  have  also  the  chancres 
of  the  infected  occurring  after  exposure  to  fresh  sources 
of  disease.  When  gummata  develop  in  the  corpora 
cavernosa,  they  are  represented  by  pea-  to  larger-sized 
nodules,  interfering  with  perfect  erection  of  the  organ. 
Very  rarely  annular  bands  form  about  the  pendulous 
portion  of  the  penis,  distinctly  circumscribed,  and  sug- 
gesting by  their  firmness  the  presence  of  a  metal  ring. 
The  chancre  situated  at  the  tip  of  the  urethra,  accom- 
panied by  a  sero-purulent  discharge  and  liable  to  be 
mistaken  for  a  blennorrhagia,  has  also  been  described. 
Deeper  gummatous  deposits  in  the  urethra  and  at  the 
base  of  the  penis  are  quite  rare.  Syphilis  of  the  pros- 
tate gland  and  of  the  seminal  vesicles  is  said  to  occur, 
but  in  the  few  rare  cases  reported  no  positive  knowledge 
is  had  respecting  the  characters  of  the  disorder. 

Gummatous  deposits  in  the  epididymis  and  the  cord 
are  decidedly  more  common  than  is  generally  supposed. 
Both  early  and  late  in  the  disease  the  globus  major  (much 
more  rarely  the  globus  minor)  of  the  epididymis  be- 
comes indurated,  inelastic,  and  at  times  somewhat 
tender.  When  thus  affected,  the  nodule  has  been  com- 
pared by  an  English  writer  to  the  condition  which  might 
be  recognized  if  an  iron  nut  were  screwed  fast  over  the 
upper  part  of  the  testicle.  One  or  both  testicles  simul- 
taneously may  be  involved,  the  distinctly  circumscribed 
firm  mass  being  readily  recognized  on  palpation.  A 
pachyvaginalitis  also  occurs  with  serous  effusion  in  the 
sac  of  the  tunica,  exactly  simulating  the  hydrocele  of 
simple  cases.  Blood,  pus,  or  serum  may  be  found  on 
exploratory  puncture,  and  the  indurated  mass  of  the 
gummatous  area  may  be  discovered  behind.  Gumma- 
tous changes  in  the  cord,  circumscribed  and  diffuse,  also 
occur  where  the  epididymis  has  been,  in  whole  or  in 
part,  the  seat  of  the  same  trouble. 

Syphilitic  orchitis  is  among  the  frequent  complications 
of  late  syphilis,  the  gummatous  change  occurring  very 
insidiously,  often  without  any  knowledge  whatever  of 


174      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

the  change  on  the  part  of  the  patient.  This  condition  is 
so  frequently  discovered  for  the  first  time  by  the  phy- 
sician in  his  examination  of  the  patient  that  it  is  wise 
in  all  cases  of  gummatous  changes  recognized  else- 
where (bones,  subcutaneous  tissue,  nervous  system)  to 
examine  with  a  special  view  to  the  recognition  of  disease 
of  the  testicle. 

When  the  body  of  the  testis  proper  is  attacked, 
fibrosis  (as  of  the  liver,  already  explained)  or  gummatous 
infiltration  may  ensue,  and  the  latter  in  either  circum- 
scribed or  diffuse  form.  A  part  or  the  whole  of  one  or 
of  both  glands  may  be  involved  ;  often  the  nodular  ele- 
vations of  the  surface  of  the  gland  may  be  recognized 
by  palpation.  In  other  cases  the  dense  induration  of  the 
testicle  may  be  determined  with  accuracy  by  the  touch 
and  by  its  well-defined  limitations,  but  the  tissue  is  quite 
smooth  and  has  the  feeling  of  marble.  The  gland  may 
be  unaltered  in  size  or  more  voluminous  than  normal, 
attaining  in  extreme  cases  the  size  of  the  largest  orange. 
The  apparent  increase  in  size  may  be  due  to  an  accom- 
panying hydrocele.  When  resolution  occurs,  the  gland 
may  slowly  diminish  in  size  by  the  absorption  of  the 
sclerotic  or  gummatous  mass,  and,  as  the  deposit  has 
usually  squeezed  the  secreting  cells  of  the  organ  to 
the  point  of  destruction,  the  ultimate  result  is  the 
shrivelling  of  the  testicle  to  a  diminutive  miniature  of 
its  former  self,  as  after  the  occurrence  of  mumps  of  the 
same  gland.  In  other  cases  the  gumma  degenerates, 
attachments  form  between  the  gland  and  the  scrotal  en- 
velopes, softening  occurs  at  a  central  point,  and  the 
gumma  bursts  with  the  subsequent  production  of  ulcer- 
ation and  fistulous  connection  of  the  testicular  mass 
with  the  integument  of  the  scrotum.  At  times,  as  a 
consequence  of  the  contractility  of  the  muscular  and 
other  parts  not  affected,  the  parenchymatous  tissue  is 
forced  through  the  scrotal  opening  until  "  benign  fungus 
of  the  testicle  "  results — a  condition  until  lately  not  well 
understood. 


SYPHILIS   OF  THE    GENITO-URINARY  ORGANS.    1 75 

In  the  matter  of  diagnosis  gonorrhoeal  epididymitis  so 
commonly  affects  the  globus  minor  that  a  distinction 
between  it  and  a  syphilitic  change  is  usually  readily 
established ;  but  it  is  not  to  be  forgotten  that  in  both 
disorders  the  location  of  the  lesion  may  be  different. 
The  exceedingly  insidious  onset  of  syphilis  of  the  epi- 
didymis or  testes  as  contrasted  with  the  acuity  of  the 
process  in  gonorrhoea  is  of  striking  importance.  It  is 
by  no  means  rare  for  the  expert  in  examining  patients 
for  syphilis  to  discover  well-advanced  changes  in  both 
testes  of  which  the  subject  of  the  disease  was  wholly 
ignorant.  Tuberculosis  of  the  testicle  commonly  begins 
with  involvement  of  the  prostate,  and  it  is  a  malady  well- 
nigh  invariably  of  those  who  are  not  victims  of  venereal 
disease.  In  syphilitic  affections  of  the  scrotum  the  lesions 
are  those  of  the  general  surface  of  the  integument,  changes 
in  their  aspect  being  due  to  friction,  motility,  heat,  and 
other  accidents  of  the  location. 

In  "Women. — In  the  genital  region  of  women,  as 
well  as  in  that  of  the  male  sex,  the  initial  scleroses 
and  consecutive  lesions  of  syphilis  are  common.  Chan- 
cres of  women  are  not  often  recognized,  by  reason  of 
their  hidden  position  within  the  vulvar  portal.  The  late 
gummatous  lesions  of  this  part  should  be  distinguished 
from  the  condition  long  termed  "  lupus  of  the  vulva " 
{estliiomene  of  Huguier).  Under  this  title  have  been 
described  gummatous  lesions  of  the  vulva,  in  which 
category  are  to  be  classed  both  circumscribed  and  dif- 
fuse indurations,  hypertrophic  growths  (as  in  strictures 
of  the  rectum  and  due  to  the  same  cause,  tongue-like 
languettes,  and  otherwise  shaped  papillomatous  masses), 
and  ulcerations  with  ragged  edges  destroying  in  whole 
or  in  part  the  ostium  vaginae  and  invading  the  region  of 
the  perineum  and  the  anus.  The  frequent  firm  oedema 
of  the  vulva  is  supposed  to  be  due  to  changes  apart 
from  the  syphilitic  process.  Cancer  of  this  region,  espe- 
cially of  the  clitoris,  is  to  be  excluded  in  establishing  a 
diagnosis,  as  is  also  Breisky's  "  kraurosis  of  the  vulva," 


176      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

a  rare  disease  accompanied  by  contraction  of  the  parts. 
Tuberculosis  of  the  vulva  is  exceedingly  rare,  and  it 
probably  occurs  with  even  greater  rarity  dissociated  from 
vaginal  lesions. 

Syphilis  of  the  vagina,  if  not  rare  of  occurrence,  is 
rarely  observed.  Chancres  and  consecutive  lesions  are 
inapt  to  form  in  the  vaginal  walls,  and  even  when  these 
are  implicated  in  gummatous  changes  the  morbid  process 
usually  spreads  to  this  mucous  surface  from  others  in  the 
vicinity.  The  urethra  of  women  may  be  the  site  of  chan- 
cres and  early  and  late  lesions  of  the  disease ;  in  very 
rare  cases  stricture  results  from  gummatous  involvement 
of  the  submucous  tissue,  especially  in  long-standing 
cases  of  syphilitic  stricture  of  the  rectum.  The  mucous 
surface  of  the  cervix  and  of  the  os  uteri  is  the  seat  of 
both  chancre  and  consecutive  lesions  more  often  than  is 
generally  supposed ;  the  former  have  previously  been 
described.  Mucous  patches  and  other  consecutive  lesions 
of  syphilis  in  this  region,  in  their  appearance  and  evo- 
lution, scarcely  differ  from  those  seen  within  the  oral 
cavity.  Care  should  be  observed,  in  formulating  a  diag- 
nosis, not  to  confound  epithelioma  of  the  os,  polypus, 
and  chancroid  with  the  lesions  of  syphilis.  The  affec- 
tions of  the  womb,  ligaments,  tubes,  and  ovaries  due  to 
syphilis  are  rare,  and  careful  investigation  of  the  subject 
is  wanting. 

The  bladder  is  rarely  the  seat  of  either  early  or  late 
syphilitic  lesions.  Proksch  is  almost  alone  in  his  re- 
searches on  the  subject  of  gummatous  changes  in  the 
vesical  walls,  with  ulceration  and  the  formation  of  a 
sinus  connecting  the  gummatous  nodule  with  the  vesical 
cavity.  Two  cases  have  been  observed  by  us ;  in  one 
case  a  papillomatous  growth  occurred  as  a  result  of 
syphilitic  changes  in  the  wall  of  the  bladder  (revealed 
by  suprapubic  cystotomy) ;  in  the  other,  a  man  sixty- 
two  years  of  age,  there  had  been  hypertrophy  of  the 
prostate  before  infection,  and  a  gummatous  mass  devel- 


SYPHILIS   OF   THE    GENITO-URINARY  ORGANS.    1 77 

oped  within  the  gland,  reaching  into  the  fundus  of  the 
bladder. 

Exulcerative  Hypertrophy  of  the  Cervix  Uteri. — 
The  uterine  neck,  at  any  time  between  the  second  and 
tenth  months  after  infection  in  women,  may  undergo  a 
species  of  chronic  induration,  and  become  the  seat  of 
total  or  partial  engorgement  and  hypertrophy,  with 
superficial  erosions  of  the  exposed  mucous  surface  and 
lesions  within  and  about  the  os  uteri.  A  scanty  semi- 
purulent  secretion  is  commonly  apparent.  The  disorder 
may  be  accompanied  by  any  of  the  several  displace- 
ments or  inflammations  of  the  utero-ovarian  system. 
Multiple  nodules  have  been  seen  clustered  about  the 
orifice ;  in  other  cases  stenosis  and  great  rigidity  have 
been  encountered.  The  larger  number  of  these  de- 
rangements are  due  less  to  the  activity  of  the  syphilitic 
virus  than  to  the  abuse  of  the  organs  common  in  women 
who  have  sustained  irregular  sexual  relations. 

Syphilis  of  the  Kidney. — The  early  changes  in  the 
kidney  due  to  syphilis  may  occur  within  a  few  months 
after  infection,  the  symptoms  being  those  of  an  acute 
nephritis  with  slowly  or  more  rapidly  developing  oedema 
of  the  face  and  the  limbs,  dysuria,  frequency  in  voiding 
the  urine,  headache,  backache,  and  profound  asthenia. 
Albumin,  blood,  epithelium,  blood-corpuscles,  and  casts 
may  all  be  present  in  the  urine.  Under  vigorous  treat- 
ment these  patients  almost  universally  recover,  even 
when  the  danger  seems  extreme.  The  organ  is  found 
enlarged  in  most  cases,  the  cortical  portion  is  increased 
in  relative  size,  and  the  tubules  are  blocked  with  epi- 
thelial debris  and  colloid  masses.  The  glomeruli  ex- 
amined with  the  microscope  may  exhibit  the  same  catar- 
rhal state  or  be  normal  in  appearance. 

In  the  late  lesions  of  the  kidney  there  is  found,  as  in 
the  liver,  a  species  of  fibrosis  ("  interstitial  inflamma- 
tion") with  resulting  contracture  and  pressure-effects 
upon  the  glomeruli,  or  gummatous  deposits,  circum- 
scribed or  diffuse,  the  latter  rather  more  rarely.     As  a 

12 


178      SYPHILIS  AND    THE  VENEREAL    DISEASES. 

consequence  of  either  process  amyloid  or  fatty  degenera- 
tion may  occur,  in  rare  cases,  simultaneously  in  the  same 
organ.  The  lardaceous  kidney  of  syphilis  is  large  and 
white  and  unilateral  or  bilateral.  At  times  good  re- 
covery ensues  where  but  one  organ  was  probably  in- 
volved. The  same  is  true  of  gummatous  changes.  In 
both  conditions  the  urine  may  contain  albumin,  blood, 
casts,  epithelium,  and  even  pus-cells.  Usually  the  cor- 
tical and  pyramidal  portions  of  the  kidney  are  involved. 
There  is  strong  reason  to  believe  that  gummatous 
changes  in  the  kidney  in  syphilis  are  of  greater  frequency 
than  is  suspected,  many  patients  recovering  from  even 
severe  renal  symptoms  without  grave  results.  It  is  to 
be  remembered  also  that  many  of  the  renal  changes 
minutely  described  in  the  treatises  on  pathology  are 
supposed  by  modern  authors  to  be  indirectly  due  to 
syphilis.  ■  The  prognosis  is  grave  when  both  organs  are 
involved  and  amyloid  degeneration  has  taken  place ; 
syphilitic  changes  in  one  kidney  or  in  a  portion  only  of 
one  are  to  be  regarded  with  greater  hopefulness.  We 
have  watched  for  fifteen  years,  after  grave  syphilitic  in- 
volvement of  the  kidney,  patients  who  suffered  from  no 
return  of  renal  symptoms.  Surgical  removal  of  a  single 
kidney  found  to  be  affected  with  syphilitic  changes  has 
been  followed  by  recovery. 

Glycosuria. — Both  glycosuria  and  diabetes  insipidus 
have  been  recognized  in  the  subjects  of  syphilis,  either  as 
co-existing  affections  or  with  the  renal  changes  due  to 
the  systemic  condition,  though  the  special  pathology  of 
such  changes  under  the  influence  of  the  syphilitic  virus 
has  not  been  studied.  As  glycosuria  is  now  recognized 
to  be  less  a  local  than  a  general  affection  of  the  economy, 
and  as  it  is  certain  that  its  origin  may  often  be  recognized 
in  tuberculosis  and  other  diseases  exerting  a  harmful 
effect  upon  the  nutrition  of  the  system,  and  especially 
upon  the  metabolic  processes,  so  it  is  believed  syphilis 
operates  in  these  cases  by  exerting  its  depressing  effects, 
even  to  the    point  of  producing  a   cachexia,  upon  the 


SYPHILIS  OF  THE   NERVOUS  SYSTEM.  1 79 

special    subjects    of   the    combination    of   the    two    dis- 
orders. 

Syphilis  of  the  Nervous  System. 
Syphilis  both  early  and  late  in  its  career  affects  the 
nervous  system,  the  earlier  manifestations  being,  for  the 
most  part,  reactive,  without  appreciable  lesion,  and  due 
chiefly  to  the  circulation  in  the  system  of  intoxicated 
blood.  Late  lesions  of  the  nervous  system  may  occur 
from  a  few  months  to  several  years  after  infection,  and 
may  result  from  syphilis  of  the  osseous  system,  pro- 
ducing indirectly  pressure  or  other  injurious  effects  upon 
the  nerves  or  the  nervous  centres  in  anatomical  rela- 
tion with  the  bones ;  or  from  syphilis  of  the  menin- 
geal coverings  of  the  nerves,  with  effects  not  widely 
different  from  those  exhibited  when  the  bones  are  in- 
volved ;  or  from  syphilis  of  the  nervous  cells  and  fibres, 
or  from  syphilis  of  the  larger  vessels  furnishing  nutrient 
material  to  the  nerves.  Gummatous  deposits  may  be 
responsible  for  the  symptoms  present  in  any  of  the 
several  complications  named,  the  evolution  and  subse- 
quent history  of  the  neoplasm  having  already  been 
described.  In  one  or  another  of  these  several  forms 
syphilis  of  the  nervous  system  occurs  more  often  in 
male  than  in  female  patients,  for  the  reason  commonly 
accepted — that  men  are,  as  a  rule,  more  than  women 
subject  to  mental  care  and  physical  fatigue  in  business 
and  toil.  By  some  authors  the  nervous  system  is 
credited  with  the  larger  number  of  all  the  so-called 
"  late  "  or  "  gummatous  "  changes  noted  in  syphilis — a 
proportion,  however,  that  is  chiefly  conspicuous  in  the 
statistics  of  experts  in  nervous  maladies.  Certain  it  is 
that  women  as  well  as  men  suffer  severely  from  the 
nervous  complications  of  the  malady;  and,  inherited 
disease  excepted,  it  is  probably  true  that  a  fatal  issue  in 
syphilis  can  more  often  be  ascribed  to  the  nervous  sys- 
tem than  to  any  other.     The  importance  of  the  recogni- 


l8o      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

tion   of  nervous   syphilis  and  the  pressing  need   of   its 
appropriate  therapy  can  scarcely  be  exaggerated. 

Syphilis  of  the  Brain  and  of  the  Cranial  Meninges. 
— In  brain-syphilis  the  effective  lesion  may  be  related 
to  any  one  of  the  conditions  noted  above.  The  com- 
monest localization  is  in  the  cortical  portion  of  the 
brain,  a  gummatous  deposit,  either  circumscribed  or 
diffuse,  directly  or  indirectly  implicating  the  meninges. 
Meningo-encephalitis  involving  extensively  one  or  both 
hemispheres,  or  a  portion  only  of  the  nervous  structure 
at  one  or  several  points,  may  result  in  varying  grades  of 
resulting  damage.  When  an  endarteritis  obliterans  (or, 
more  rarely,  a  mesarteritis  or  a  periarteritis)  occurs,  the 
injury  is  by  thrombosis  and  subsequent  occlusion,  or  by 
the  formation  of  small  aneurysms  as  in  syphilis  of  the 
blood-vessels,  or  by  dislodgement  of  one  or  more  frag- 
ments of  an  embolus  and  their  later  transference  in  the 
blood-current  to  points  at  a  distance  from  a  forming 
neoplasm.  For  the  localization  of  the  nervous  lesion  by 
the  aid  of  the  symptoms  in  any  case  presented,  the 
student  is  referred  to  the  results  of  the  admirable  studies 
of  this  theme  presented  in  the  works  on  general  pa- 
thology. Collectively,  the  symptoms  may  be  described 
as,  first  and  most  common,  headache,  usually  character- 
istically severe,  of  a  boring,  hammering,  constricting,  or 
grinding  character,  generally  with  very  distinct  nocturnal 
exacerbation,  accompanied  or  not  by  vomiting,  and  at 
times  terminating  in  relief  in  the  most  capricious  man- 
ner. This  pain  may  be  aggravated  by  percussion  or 
pressure  over  certain  points  of  the  cranium,  and  often  is 
marked  along  the  lines  traced  by  the  distribution  of  the 
trigeminus.  A  striking  feature  of  all  these  disorders  is 
the  multiformity  of  the  symptoms  present  and  their 
capriciousness  as  to  grave  or  insignificant  results.  Thus, 
symptoms  of  coma  or  of  paralysis  may  appear  or  dis- 
appear in  a  way  utterly  impossible  without  grave  se- 
quence in  any  non-syphilitic  disease.  The  multiformity 
so  characteristic  of  the  surface  symptoms  of  the  disease 


SYPHILIS   OF   THE  NERVOUS  SYSTEM.  l8l 

is  often  striking  when  the  nervous  system  is  attacked. 
Mental  hebetude,  stupor,  coma  of  insidious  beginning, 
convulsions,  or  a  seizure  simulating  that  of  epilepsy,  but 
different  from  it  in  that  the  average  patient  does  not 
wholly  lose  consciousness,  may  each  be  significant.  Of 
equal  importance  may  be  named  hemianopsia,  motor  or 
sensory  aphasia,  disturbances  of  olfaction  or  of  taste,  per- 
sistent dilatation  of  one  pupil,  or  paralysis  of  a  single 
muscle  or  of  a  capriciously  selected  group  of  muscles 
within  the  orbit. 

When  syphilis  affects  the  larger  ganglia,  the  gumma- 
tous deposit  is  less  likely  to  be  implanted  in  the  nervous 
tissue  proper  than  in  the  walls  of  the  larger  vessels, 
especially  those  of  the  middle  cerebral  artery,  the  com- 
plete or  even  partial  occlusion  of  which  by  an  obliterat- 
ing arteritis  is  apt  to  be  followed  by  a  monoplegic  or 
hemiplegic  attack,  the  consequences  of  which  may  be 
serious.  Here  the  onset  of  the  disease  may  be  insidious 
and  unaccompanied  by  the  chain  of  symptoms  of  brain- 
syphilis  ;  or  all  these  may  be  present,  with  severe  head- 
ache, mental  hebetude,  and  even  coma.  As  a  rule, 
however,  the  patient  suffering  from  a  syphilitic  hemi- 
plegia is  entirely  conscious,  and,  though  for  weeks 
previous  the  victim  of  an  agonizing  cephalalgia,  is  re- 
lieved of  most  of  the  cranial  distress  when  motor  paral- 
ysis is  established.  The  reflexes  of  the  wrist,  of  the 
elbow,  of  the  knee,  and  of  the  ankle  are  usually  exag- 
gerated in  the  paralyzed  extremities  both  after  and  before 
the  seizure.  It  will  be  remembered  that  in  consequence 
of  decussation  of  fibres,  the  gummatous  changes  of  one 
side  of  the  brain  are  for  the  most  part  responsible  for 
paralytic  phenomena  of  the  other.  Recovery  may  be 
relatively  rapid  in  the  course  of  a  few  weeks,  or  it  may 
require  years  for  its  completion.  In  some  cases  the 
damage  done  is  irreparable,  and  contractures  result  in 
both  upper  and  lower  extremities ;  the  speech  becomes 
mumbling,  and  the  patient,  while   life  is  yet  conserved, 


1 82      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

reaches  in  almost  every  function  of  the  body  one  of  the 
lower  levels  of  physical  degradation. 

Lesions  of  the  crus  are  apt  to  be  betrayed  in  oculo- 
motor paralyses  associated  with  hemiplegia  of  the  other 
side  of  the  body,  while  those  of  the  pons  are  liable  to  be 
followed  by  facial  paralysis  in  which  the  arm  and  the 
leg  of  the  opposite  side  are  involved.  In  the  case  of 
affection  of  the  medulla  there  is  often  a  similar  associa- 
tion of  paralyses — a  hemiplegia  of  one  side  and  an  in- 
volvement on  the  other  of  the  vagus,  glosso-pharyngeal, 
hypoglossal,  or  other  nerves  whose  nuclei  have  a  medul- 
lar site.  There  may  be  also  a  bilateral  palsy  of  the  four 
extremities,  the  result  depending  upon  the  extent  of 
gummatous  change  in  the  meninges. 

Paralyses  of  the  oculo-motorius  are  so  frequent  in 
syphilis  that  their  occurrence  always  leads  to  special  in- 
quiries on  the  part  of  the  careful  diagnostician  respecting 
a  possible  syphilitic  origin.  The  third,  sixth,  and  fourth 
nerves  (most  commonly  the  two  first  named)  may,  when 
affected,  produce  ptosis,  paralysis  of  the  superior  oblique, 
external  and  internal  recti,  and  failure  of  accommodation 
to  light.  The  capriciousness  with  which  one  or  more 
of  the  muscles  innervated  by  these  trunks  are  selected 
for  attack  is  highly  characteristic  of  syphilis. 

Syphilis  of  the  Cord  and  of  the  Meninges. — The 
symptoms  of  syphilis  of  the  cord  and  its  coverings  are 
spastic  paralysis  of  both  lower  extremities,  involuntary 
action  of  the  rectum  and  the  bladder,  exaggeration  of 
some  or  all  of  the  tendon  reflexes,  contractures  of  mus- 
cles, particularly  of  the  adductors  of  the  thighs,  more  or 
less  anaesthesia,  a  tendency  to  the  formation  of  bed-sores, 
and,  in  cases,  pains  of  a  severe  character  in  the  loins  and 
the  lower  limbs.  These  changes  may  result  from  gum- 
matous deposits  in  the  vertebrae  or  in  the  meninges  of 
the  cord,  or  from  a  distinct  specific  myelitis  or  meningo- 
myelitis  occurring  in  the  cervical,  dorsal,  or  lumbar 
region,  one  or  all.  Other  symptoms  which  may  be 
present  in  exceptional  cases  are  changes  in  the  ocular 


SYPHILIS    OF   THE   NERVOUS  SYSTEM.  1 83 

system  (for  example,  persistent  dilatation  of  one  pupil), 
in  the  genital  system  (increased  or  diminished  sexual 
desire  and  vigor),  and  paralysis  limited  to  wrist-drop  of 
both  upper  extremities,  to  cephalalgia,  to  aphasia,  etc. 

Syphilis  and  Tabes. — The  etiological  relation  of 
syphilis  to  tabes  has  been  the  fertile  source  of  a  con- 
troversy which  has  at  last  been  settled  by  an  over- 
whelming preponderance  of  testimony,  derived,  for  the 
most  part,  from  evidence  furnished  not  so  much  by 
syphilologists  as  by  the  statistics  of  insane  asylums. 
Syphilis  is  without  question  a  precedent  fact  in  more 
than  90  per  cent,  of  all  cases  of  tabes.  Mobius  has 
well  stated  that  tabes  and  general  paralysis  of  the  insane 
are  instances  of  "  meta-syphilis,"  and  are  one  in  origin, 
with  a  distinction  chiefly  in  the  localization  of  their 
organic  changes.  Patients  affected  with  these  sequels 
of  syphilis  are  in  the  category  of  those  little  benefited 
by  treatment  for  specific  disease.  Here,  as  in  other 
ailments  following  infection,  it  seems  that  the  result  is 
less  directly  due  to  the  toxic  agents  of  the  malady  than 
to  some  chain  of  factors  set  in  operation  by  the  syphilitic 
germ. 

The  symptoms  of  tabes  dorsalis  in  syphilis  and  in  a 
presumably  small  minority  where  syphilis  has  at  least 
not  been  proven  are  the  same,  and  for  a  description  of 
these  symptoms  the  reader  is  referred  to  treatises  on 
general  medicine.  Care  should  always  be  taken,  in 
establishing  a  diagnosis,  to  avoid  setting  down  as  symp- 
toms of  syphilis  those  due  to  other  changes  in  the  cord ; 
as,  for  example,  when  there  is  a  loss  of  one  or  more  bones 
of  the  digits  of  the  feet,  or  when  from  the  same  cause 
the  nails  are  exfoliated. 

The  existence  of  the  Argyll-Robertson  pupil  (reflex 
iridoplegia ;  loss  of  reflex  to  direct  light,  and  preserva- 
tion of  sharp  power  of  contraction  on  convergence)  is 
a  feature  of  the  greatest  importance  in  establishing  a 
diagnosis  of  tabes  and  of  general  paralysis,  though 
authorities    differ  as   to  its  import  when  attempting  to 


184      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

distinguish  between  cerebral  syphilis  and  the  tabes  and 
general  paralysis  of  both  accepted  syphilitic  and  sup- 
posed non-syphilitic  origin.  The  readiest  means  of  de- 
termining the  state  of  the  ocular  reflexes  in  doubtful 
cases  is  to  seat  the  patient  before  a  strong  light  and 
with  a  distant  object  in  view.  The  physician  then  covers 
with  his  hands  or  with  a  card  the  widely  opened  eyes 
of  the  patient,  and  after  an  interval  of  between  ten  and 
twenty  seconds  suddenly  exposes  the  eyes  to  the  light. 
If  the  iris  under  these  conditions  remains  immobile,  it  is 
only  necessary  to  distinguish  this  condition  from  paral- 
ysis of  the  same  organ  by  asking  the  patient  to  look  at 
the  tip  of  his  own  nose  or  at  the  face  of  the  physician 
in  close  proximity.  When  the  pupil  rapidly  contracts 
under  these  circumstances  it  is  clear  that  the  contractility 
of  the  iris  is  preserved,  and  that  the  iridoplegia  is  a 
symptom  of  some  cerebral  affection.  When,  in  connec- 
tion with  the  ocular  phenomena,  there  are  absence  of  the 
tendon-reflexes,  slight  or  severe  lancinating  pains  (usu- 
ally in  the  lower  extremities,  but  also  located  elsewhere), 
vesical  irritability  (difficulty  in  starting  the  urinary 
stream,  "  stammering  of  the  bladder,"  the  necessity  in 
the  case  of  male  patients  of  assuming  the  seated  posture 
in  order  to  evacuate  the  bladder,  and  occasionally  re- 
tention), various  minor  paralyses,  paraesthesiae,  tachy- 
cardia, and  ataxic  symptoms,  the  diagnosis  is  for  the 
most  part  clear. 

Cerebro  -  spinal  syphilis  (multiple  cerebro  -  spinal 
syphilis)  is  a  term  employed  to  indicate  those  cases  in 
which  there  is  simultaneous  involvement  of  both  brain 
and  cord.  The  number  of  these  cases  is  larger  than  is 
commonly  believed. 

Dementia  Paralytica  and  other  Mental  States  due 
to  Syphilis. — It  is  exceedingly  difficult  to  ascribe  to  the 
proper  cause  the  many  singular  and  diverse  mental 
states  recognized  in  syphilitic  subjects.  It  is  to  be  re- 
membered that  of  a  thousand  victims  of  infection  a  cer- 
tain proportion   were  before   the    accident   predisposed 


SYPHILIS    OF   THE   NERVOUS  SYSTEM.  1 85 

strongly,  from  other  influences  (heredity,  accident,  etc.), 
to  nervous  disease,  and  that  many  others,  during  the 
long  course  of  treatment  required  for  the  relief  of  syph- 
ilis, are  exposed  to  numerous  influences  tending  to  in- 
duce mental  states  of  a  morbid  character  (business  re- 
verses, affliction,  accidents).  It  is  not  very  rare  to  find 
grave  states  of  hypochondria  leading  to  self-destruction 
in  a  certain  class  of  young  subjects  of  both  sexes  after 
infection ;  and  transient  dementia  is  occasionally  en- 
countered, with  and  without  hallucinations  and  stupor. 
In  these  cases,  as  Sachs  has  shown,  very  remarkable 
intermissions  and  recovery  stamp  the  disorder  as  due 
only  to  lues.  The  persistent  dementias  which  prove 
complete  are,  fortunately,  rare  in  syphilis.  They  usually 
follow  the  graver  lesions  of  the  nervous  centres. 

Dementia  paralytica  of  the  alienists  (delire  des  gran- 
deurs, general  paresis),  with  epileptiform  and  apoplectic 
seizures,  mental  hebetude  leading  to  failure  of  almost 
all  the  mental  faculties,  pupillary  inequalities,  tremor 
in  articulating  (lips  and  tongue),  with  singular  changes 
in  the  moral  qualities  of  the  individual,  is,  like  tabes 
dorsalis,  amply  delineated  in  the  descriptions  to  be 
found  in  the  best  works  on  nervous  diseases.  It  is 
stated  above  that  general  paresis  and  tabes  are  both 
parasyphilitic  conditions,  similar  in  their  etiology,  path- 
ology, and  career,  and  differing  in  symptoms  chiefly  by 
reason  of  the  different  sites  of  their  organic  lesions.  To- 
day there  is  no  question  in  the  minds  of  the  experts  of 
large  experience,  chiefly  those  engaged  in  institutions 
for  the  insane,  that  syphilis  is  a  precedent  fact  in  a  great 
majority  of  all  cases.  As  in  the  instance  of  tabes,  the 
infective  process  seems  to  be  rather  an  indirect  than  a 
direct  cause  of  the  issue.  The  frequent  relation  of  tabes 
with  dementia  paralytica  would  alone  suggest  the  syph- 
ilitic origin  of  the  last-named  disorder,  even  if  statistics 
were  not  at  hand  to  confirm  the  fact. 

Syphilis  of  the  Peripheral  Nerves. — The  cephalalgias 
of  nervous  syphilis  are,  without  question,  at  times  rep- 


1 86      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

resented  by  neuralgias  due  to  specific  involvement  of  the 
peripheral  nerves.  "  Syphilitic  sciatica  "  is  as  distinctly 
a  symptom  of  a  condition  recognized  in  the  subject  of 
lues  as  is  nocturnal  cephalalgia ;  and  cases  are  recorded 
in  which  gummata  of  bone  and  of  other  tissues  in  the 
tract  of  a  nerve-trunk  have  by  compression  or  other 
accidents  induced  serious  changes  in  the  nerves  them- 
selves. 

Syphilis  of  the  Eye  and  Ocular  Appendages. 

The  lachrymal  gland  is  rarely  involved  either  in  a 
primary  gummatous  infiltration  or  secondarily  as  a  result 
of  implication  of  other  organs  in  the  orbit.  The  same  is 
true  of  the  lachrymal  caruncle,  which  may  become  tumid, 
engorged,  dense,  and  eventually  the  site  of  ulceration  in 
the  rare  cases  in  which  it  has  been  found  diseased.  The 
canaliculi,  the  puncta,  the  sac,  and  the  nasal  duct  may  be 
involved  in  any  one  of  the  early  or  late  manifestations 
of  syphilis  when  the  eye  is  involved,  usually  as  the 
result  of  some  lesions  in  the  vicinity,  as,  for  example, 
chancres,  papules,  tubercles,  ulcers  of  the  edges  of  the 
lids,  iritis  with  its  frequent  accompaniment  of  conjunc- 
tivitis, and  the  panophthalmias  seen  in  filthy  and  des- 
titute charity  patients  in  dispensary  practice.  Again, 
many  of  the  syphilitic  lesions  of  the  nasal  passages  lead  in- 
directly to  catarrhal  and  purulent  inflammatory  affections 
of  the  sac.  Periostitis  of  the  bones  forming  the  nasal 
cavity  is  a  frequent  source  of  these  purulent  catarrhs. 
Stricture  and  eventual  obliteration  of  the  duct  may 
result  either  from  gummatous  deposits  in  the  mucous  or 
submucous  tissue  or  from  osteo-periosteal  changes  in  the 
channel.  The  external  symptoms  of  these  affections  are 
epiphora,  a  swelling  of  the  part,  and  tenderness  with  a 
sense  of  fulness.  There  is  commonly  evacuation  of  a 
sero-purulent  fluid  when  pressure  is  exerted  over  the 
tumor.  Eventually  there  may  be  abscess  and  ulceration 
at  the  point  of  bursting.  The  osteoplastic  metamor- 
phosis of  the  bony  walls  of  the  canal,  described  hereto- 


SYPHILIS  OF  THE  E  YE  AND  OCULAR  APPENDAGES.    1 87 

fore  as  eburnation  (one  of  the  varieties  of  formative 
osteitis),  occasionally  occludes  the  duct  by  the  formation 
of  a  growth  which  chokes  its  calibre ;  but  more  often 
the  bony  changes  here  are  in  the  line  of  caries  and 
necrosis,  relieved  by  spontaneous  or  artificial  removal  of 
segments  of  bone. 

Syphilis  of  the  eyelids  may  be  exhibited  in  chancres 
or  in  the  syphilodermata  of  systemic  disease,  such  lesions 
being  located  either  on  the  edge,  on  the  conjunctival 
surface,  or  on  the  cutaneous  covering  of  the  lid.  In  the 
case  of  chancre  the  diagnosis  is  readily  made  when  con- 
sideration is  had  of  the  induration  of  the  lesion  and  its 
bubo,  the  enlarged  gland  being  usually  the  pre-auricular 
of  the  involved  side.  Eyelid-chancre  has  the  usual 
characteristics  of  chancres  seen  elsewhere  and  pre- 
viously described,  the  chief  peculiarities  of  the  site  being 
an  enormous  tumefaction  of  the  lid  that  occasionally 
(not  invariably)  results,  and  the  consequent  epiphora  and 
photophobia.  When  the  initial  sclerosis  ulcerates,  the 
excavation  is  shallow  and  oval,  with  elevated  edges, 
densely  sclerosed  base,  and  a  floor  secreting  rather  more 
freely  than  chancres  in-  other  situations,  on  account  of 
the  irritation  to  which  it  is  subjected. 

Syphilodermata  are  more  frequently  found  on  the 
cutaneous  surface  of  the  eyelid;  rarely  an  isolated 
lesion  or  several  lesions  may  be  discovered  on  the 
conjunctival  surface;  but  in  our  experience  these 
accidents  result  most  commonly  from  special  causes 
inciting  the  mucous  membrane  to  morbid  activity  (trau- 
matism, iodism,  foreign  bodies  beneath  the  lid).  Gum- 
mata,  when  present,  form  nearer  the  free  border  of  the 
lids  than  elsewhere ;  they  may  be  single  or  multiple  in 
this  region,  and  their  ulcers,  when  they  degenerate,  are 
characteristic.  When  the  tarsus  is  infiltrated  with  a 
gummatous  deposit,  a  firm  tumor  results,  implicating  the 
entire  lid  (usually  the  upper)  or  but  a  portion  of  it,  with 
and  without  involvement  of  the  cutaneous  surface.  Here, 
as  in  syphilis  of  the  testis  and  the  liver,  after  complete 


1 88      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

absorption  of  the  neoplasm  has  been  effected  the  tarsus 
may  lose  its  original  texture  and  elasticity. 

The  conjunctiva  may  be  the  seat  of  any  one  of  the 
processes  previously  described  in  connection  with  syph- 
ilis of  the  mucous  membrane,  save  that  the  limitations 
of  the  area  involved  and  the  large  portion  of  it  that  is 
protected  by  apposition  of  contiguous  surfaces  save  it 
from  many  of  the  sources  of  disease  to  which  the  lining 
membrane  of  the  mouth  and  of  the  nares  is  especially 
subject.  Chancres  of  the  conjunctiva  have  been  reported 
without  implication  of  the  lid,  but  they  are  exceedingly 
rare.  When  present,  they  are  most  often  found  in  the 
palpebral  conjunctiva,  near  the  lid-margin,  as  dense 
circular  indurations,  often  capped  by  a  superficial  erosion 
having  a  grayish  floor.  Papules,  tubercles,  pustules, 
mucous  patches,  and  ulcers  occur  upon  the  conjunctiva 
as  elsewhere,  and  are  readily  recognized  by  the  symp- 
toms heretofore  described.  Ulceration  of  the  conjunc- 
tiva, whether  from  breaking  down  of  a  gumma  or  as 
the  result  of  pustulation  of  the  surface,  occurs  at 
one  or  many  points  with  superficial  losses  of  tissue, 
circumscribed,  with  uneven  base,  covered  usually  with 
a  more  or  less  adherent  yellowish-white  film,  beneath 
which  the  surface  is  eroded.  On  the  free  edge  of  the 
lid  the  ulceration  often  assumes  a  linear  shape  and 
spreads  along  the  entire  edge,  excavating  its  thickness. 
Rarely,  extensive  sloughs  form.  Cases  are  recorded  in 
which  gummata  of  the  ocular  conjunctiva  produced  an 
annular  infiltration  surrounding  the  cornea,  which,  after 
degeneration  of  the  former,  resulted  in  necrosis. 

Syphilis  of  the  cornea  occurs  either  in  the  form  of 
an  interstitial  keratitis,  with  points  of  opacity  usually 
at  first  centrally  situated,  spreading  thence  outward 
and  involving  the  deeper  layers,  which  later  and  in 
a  secondary  stage  may  become  vascularized;  or  the 
opacity  spreads  from  the  periphery  to  the  centre,  and 
eventually  produces  the  characteristic  "  ground-glass " 
appearance  of  the  cornea.     In  another  form  there  are 


SYPHILIS  OF  THE  E  YE  AND  OCULAR  APPENDAGES.    1 89 

definite  points  of  opacity,  the  puncta  being  pin-point 
to  pin-head  in  size,  usually  not  numerous  though  multi- 
ple, the  transparency  of  the  unaffected  portions  of  the 
cornea  being  unaltered.  Gummatous  deposits  in  the 
cornea,  of  the  type  of  the  gumma  of  other  regions,  have 
occasionally  been  observed.  When  the  stage  of  vascu- 
larization is  reached,  fine  vessels  may  be  seen  deeply 
penetrating  the  cornea  at  its  periphery.  When  com- 
plete, the  cornea  looks  like  raw  beef  and  the  irritative 
symptoms  are  pronounced.  The  accompanying  lachry- 
mation,  pain,  and  neuralgias  may  be  slight  or  severe. 

Syphilis  of  the  sclerotic  is  betrayed  in  superficial  and 
parenchymatous  forms  of  scleritis,  some  authors  describ- 
ing a  gummatous  form  as  distinct  from  the  latter,  the 
difference  in  all  being,  however,  one  chiefly  of  external 
appearance  of  the  lesion.  In  the  milder  cases  dark- 
tinted,  even  empurpled  patches  occur,  of  congestive 
aspect,  with  thickening  of  the  tissues  and  obvious  in- 
volvement of  the  overlying  conjunctiva.  These  maculae 
may  be  single  or  multiple;  they  are  rarely  very  numer- 
ous, and  are  said  never  to  form  a  pericorneal  zone, 
though  extreme  cases  occur  where  the  deep  congestion 
involves  a  large  part  of  the  exposed  sclera.  There  is 
usually  some  pain,  although  at  times  none  is  experienced. 
Iritis  is  rarely  present.  In  the  parenchymatous  form  all 
the  symptoms  above  described  are  exaggerated  and  com- 
plications are  more  common.  The  disorder  is  really  a 
diffuse  gummatous  change,  as  distinguished  from  the 
circumscribed  forms  of  gummatous  deposit,  in  which 
elevated  or  flattened  nodules,  usually  developing  on  the 
temporal  side  of  the  globe,  exhibit  telangiectases  over- 
lying the  conjunctiva. 

Syphilis  of  the'  iris  is  the  most  common  of  all 
luetic  affections  of  the  eye.  Iritis,  acute,  subacute, 
or  chronic,  occurs  both  early  and  late  after  infection, 
much  more  often  seen  after  the  involution  of  the 
chancre,  the  syphilitic  representing  nearly  75  per  cent, 
of  all    cases   of  the    malady    presented.       Usually    but 


I90      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

one  eye  is  affected,  rarely  both.  Recurrences  are  apt 
to  be  limited  to  the  organ  originally  involved.  In 
our  experience  there  is  usually  an  exciting  cause  even 
when  syphilis  is  present,  determining  the  onset  of  the 
affection  and  even  its  selection  of  a  weak  eye.  For  ex- 
ample, there  are  few  experts  in  the  cities  of  the  North 
who  have  not  noted  an  increase  in  the  number  of  cases 
of  iritis  in  a  group  of  syphilitic  patients  treated  after  the 
streets  have  suddenly  been  covered  with  snow.  Forms 
of  plastic,  serous,  and  gummatous  iritis  are  described  by 
authors,  the  three  forms  being  distinguished  merely  by 
a  preponderance  of  one  or  more  symptoms  present  in 
any  given  case.  The  chief  symptoms  regularly  noted 
on  the  part  of  the  patient  are  photophobia,  lachrymation, 
deep-seated  pain,  and  imperfect  vision ;  while  the  physi- 
cian recognizes  tumefaction  and  a  change  of  color  in 
the  affected  iris ;  irregularity  of  the  pupillary  opening, 
due,  as  a  rule,  to  posterior  synechias,  giving  an  oval,  at 
times  even  a  jagged,  outline  to  the  pupil ;  marked  slug- 
gishness of  the  iris  when  light  is  suddenly  admitted  to 
it ;  and  deep  ciliary  injection,  distinguished  by  radii  of 
straight  pinkish  vessels  forming  a  halo  about  the  cornea 
and  contrasting  vividly  with  the  longer,  more  tortuous, 
and  brick-colored  vessels  set  superficially,  deeply  en- 
gorged, and  belonging  to  the  conjunctiva.  In  the  forms 
of  serous  iritis  of  authors  the  aqueous  humor  is  turbid, 
the  tension  of  the  eyeball  is  increased,  and  the  field  of 
the  pupil,  especially  near  the  margin  of  the  iris  and  the 
posterior  face  of  the  cornea  and  of  the  iris,  becomes  the 
seat  of  exudative  deposits.  The  term  "  gummatous 
iritis"  (parenchymatous  iritis)  is  by  some  authors  limited 
to  the  distinct  formation  of  nodes,  papules,  or  reddish- 
yellow  tubercles  within  the  substance  or  on  the  sur- 
face of  the  iris ;  but  it  is  probable  that  all  syphilitic 
forms  of  iritis  are  due  chiefly  to  gummatous  deposits 
even  when  no  circumscribed  nodules  appear  on  the  an- 
terior face  of  the  curtain. 

The  prognosis  of  all  forms  of  iritis  is  good.     The  chief 
danger  arises  from  adhesion  of  the  iris  to  the  capsule 


SYPHILIS  OF  THE  E  YE  AND  OCULAR  APPENDAGES.    1 91 

of  the  lens  as  a  consequence  of  posterior  synechia — a 
complication  which  may  usually  be  set  aside  by  the  pro- 
duction of  extreme  mydriasis.  Glaucoma  and  hypopion 
result  in  a  very  small  proportion  of  cases. 

Syphilis  of  the  Ciliary  Body. — Serous,  plastic,  and 
gummatous  forms  of  cyclitis  are  recognized,  the  chief 
difference  between  them  being  the  mode  of  gummatous 
infiltration,  all  being  due  to  deposit  of  gummatous 
material  either  in  diffuse  or  in  circumscribed  form. 
When  the  ciliary  body  is  implicated  the  symptoms  are 
the  following :  visual  disturbance  in  various  grades ; 
usually,  not  invariably,  diminished  tension ;  ciliary  in- 
jection ;  and  an  exudation  varying  in  amount  and  cha- 
racter within  the  posterior  chamber,  and  at  times  also 
involving  the  vitreous.  The  iris  is  hypersemic;  the 
anterior  chamber  abnormally  deep ;  the  pupil  dilated. 
Often  the  symptoms  of  iritis  and  of  choroiditis  are  present, 
and  the  disease  is  then  properly  described  as  "  irido- 
choroiditis."  In  well-marked  cases  the  attached  por- 
tions of  the  iris  are  pushed  forward  by  the  vis  a  tergo 
of  the  exudate,  blocking  up  the  pupil  and  distending  the 
posterior  chamber,  while  its  free  border  is  more  or  less 
fixed  by  posterior  synechiae.  Glaucoma  or  softening  of 
the  globe  may  result,  and  the  issue  is,  in  general,  grave. 
The  gummatous  material,  whether  deposited  in  points 
on  the  membrane  of  Descemet  or  spreading  to  the  ciliary 
body  from  nodules  on  the  face  of  the  iris,  undergoes 
changes,  either  by  resolution  or  by  disintegration,  not 
different  from  those  recognized  in  other  portions  of  the 
globe. 

Syphilis  of  the  choroid  is  more  common  than  any 
luetic  affection  of  the  eye  save  iritis  ;  in  point  of  serious- 
ness, while  not  so  grave  in  the  majority  of  cases  as  cyc- 
litis, the  affection  may  result  in  irreparable  damage.  The 
symptoms  are,  in  general,  clouding  of  the  vitreous  humor 
by  reason  of  exudates  forming  fixed  or  floating  specks, 
fibrils,  threads,  membranes,  or  even,  in  extreme  cases, 
semi-solid  masses  of  irregular  form  occupying  either  the 
anterior  or  the  posterior  half  of  the  choroid,  and  accom- 


I92      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

panied  or  not  by  retinitis  and  disturbance  of  vision  in 
various  degrees.  Iritis  is  a  complication  when  the  ante- 
rior portion  of  the  choroid  is  chiefly  involved,  retinitis 
when  the  posterior  segment  is  affected.  There  occur 
rapid  diminution  of  ocular  tension,  deep-seated  pain,  pho- 
tophobia, metamorphopsia,  hemeralopia,  and  amaurosis 
in  various  degrees  of  severity.  The  remote  results  of 
these  serious  changes  are  the  formation  of  staphyloma, 
cataract,  detachment  of  the  vitreous,  and  ultimate  atrophy 
and  shrinkage  of  all  the  constituent  coats  of  the  eye.  By 
the  aid  of  the  ophthalmoscope  in  well-marked  choroiditis 
whitish-yellow  or  reddish-yellow  patches,  fairly  well  cir- 
cumscribed, can  be  recognized  about  the  posterior  pole 
of  the  ocular  axis,  often  with  a  distinctly  pigmented  halo 
and  with  a  tendency  to  atrophy  of  the  tissue  in  which 
they  have  developed.  As  the  disease  progresses  the  yel- 
lowish hue  of  these  patches  is  replaced  by  white,  indi- 
cating that  the  choroid  has  lost  its  pigment  and  that  the 
sclera  is  exposed. 

The  crystalline  lens  and  the  vitreous  humor,  when 
attacked  in  syphilis,  always  exhibit  nutritional  changes 
secondary  to  morbid  processes  in  the  uveal  tract. 

Syphilis  of  the  retina  furnishes  a  list  of  grave  dis- 
orders as  respects  vision.  Chorio-retinitis  is  practically 
a  complication  of  choroiditis,  as  already  described. 
When  the  retina  is  distinctly  involved,  a  membranous 
film  appears  to  be  stretched  between  it  and  the  observer. 
There  is  also  scotoma  and  deficient  central  vision.  The 
forms  of  pure  retinitis  where  the  choroid  is  not  involved 
are  rare.  By  the  aid  of  the  ophthalmoscope  it  can  be 
seen  that  the  fundus  of  the  eye  is  the  seat  of  "  spots  of 
exudation,"  variously  sized  and  irregularly  distributed,  at 
first  markedly  cedematous ;  later,  as  a  result  of  atrophy 
of  the  retina,  blackish  when  the  choroid  has  been  entered. 
If  the  choroid  also  atrophies,  these  spots  acquire  a 
whitish  centre,  with  a  blackish  fringe  at  the  periphery. 
The  symptoms  are  hemeralopia,  lachrymation,  photo- 
phobia, diminution    of  central    vision,    and   the    appear- 


SYPHILIS  OF  THE  E  YE  AND  OCULAR  APPENDAGES.    1 93 

ance  to  the  patient  of  bright  circles  or  patches  which 
revolve  about  the  point  on  which  the  eye  is  fixed. 
When  a  distinct  exudation  occurs  the  inner  layers  of 
the  retina  are  involved,  and  indistinctly  circumscribed 
elevatipns  occur  chiefly  about  the  posterior  pole  of 
the  eye.  When,  as  a  result  of  these  or  of  the  other 
changes  in  syphilitic  disease  of  the  retina,  hemorrhages 
occur,  the  symptoms  and  appearance  are  those  of  simi- 
lar complications  in  non-specific  disease.  The  "  central 
recurrent  retinitis  "  of  Von  Graefe  is  exhibited  in  opaci- 
ties about  the  macula,  which  disappear  at  the  time  of  the 
improvement  of  the  vision,  but  which  may  return  with 
the  production  of  characteristic  streaks  radiating  from 
the  disk  along  the  lines  of  the  vessels. 

The  optic  nerve  may  be  affected  by  syphilis  either 
within  the  cerebral  tissue,  within  the  orbit,  or  between 
the  orbit  and  the  brain,  and  as  a  result  either  of  morbid 
changes  in  the  adjacent  tissues  (bones  of  the  orbit  or 
foramen)  or  of  primary  involvement  of  the  nerve-tissue. 

Papillitis  (inflammation  of  the  intraocular  extremity 
of  the  nerve)  is  betrayed  by  tumefaction  of  the  disk 
(with  its  outline  obscured  by  surrounding  oedema), 
venous  stasis,  and  arterial  stenosis.  The  surface  is 
marked  by  radiating  striae  fading  into  the  surrounding 
retina ;  centrally  the  larger  retinal  vessels  are  visible. 
When  both  eyes  are  thus  affected,  and  they  exhibit 
signs  of  choked  disk,  the  diagnosis  is  of  an  intracranial 
lesion  (gumma  of  bone,  vessel,  meninges).  When  but  a 
single  eye  is  involved,  the  source  of  the  trouble  may  be 
wholly  within  the  orbit.  There  may  be  amblyopia, 
hemianopsia,  or  more  or  less  complete  amaurosis.  Pres- 
ervation of  fairly  good  visual  power  with  symptoms  of 
choked  disk  is  supposed  to  be  due  to  the  integrity  of  the 
layer  of  cones  and  rods  in  the  retina. 

In  neuritis  descendens  of  one  side  the  lesion  obviously 
has  existed  between  the  chiasm  and  the  orbit;  when  both 
sides  are  involved,  the  lesion  is  situated  posterior  to  the 
chiasm.     In  these  cases  the  change  occurs  primarily  in 

13 


194      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

the  tissues  outside  the  nerve-sheath,  the  latter  being 
secondarily  involved,  as  are  also  the  nervous  fibrillae 
within  the  sheath.  The  most  common  causes  are  arter- 
itis, mesarteritis,  endarteritis,  meningitis,  and  gummata 
of  the  encephalic  nervous  tissue. 

Atrophy  of  the  optic  nerve  may  result  from  any  of  the 
changes  described  above,  or  from  encephalic  or  spinal 
disease.  The  differences  between  the  inflammatory, 
cerebral,  and  spinal  forms,  as  distinguished  by  the  oph- 
thalmoscope, are  chiefly  color-changes  in  the  optic  disk 
from  a  grayish-blue  to  a  bluish-green  shade,  and  the 
various  degrees  of  reduction  in  size  of  the  arteries  and 
the  veins,  the  picture  being  more  or  less  hidden  by  an 
obscuring  mist.  In  some  cases,  however,  no  ophthal- 
moscopic changes  can  be  recognized,  and  the  location 
of  the  site  of  the  effective  lesion  must  be  inferred  from 
other  symptoms.  In  hemiopia  fugax  (flittering  scotoma) 
and  true  hemianopsia  the  lesion,  without  visible  ophthal- 
moscopic changes,  is  probably  seated  in  one  optic  tract. 
The  subjective  symptoms  are  a  reduction  of  central  acuity 
with  contraction  of  the  peripheral  field,  and  a  diminution 
of  color-sense  and  light-sense;  occasionally  vision  is 
improved  in  a  relatively  dim  light. 

Syphilis  of  the  ocular  muscles  has  already  been 
described  in  connection  with  the  subject  of  nervous 
lesions.  It  is  merely  needful  to  repeat  here  that  the 
great  majority  of  all  cases  of  disturbance  of  function  of 
these  muscles  is  due  not  to  a  specific  myositis,  but  to 
intracranial  lesions  (pachymeningitis,  obliterating  arterial 
disease,  etc.). 

Syphilis  of  the  bony  walls  of  the  orbit  is  exhibited 
in  osseous  changes  of  the  types  already  described  in 
connection  with  bone-syphilis,  periostitis,  osteo-perios- 
titis,  hyperostosis,  exostosis,  caries,  and  necrosis,  these 
conditions  representing  a  series  of  changes  due  to  the 
evolution  of  a  gummatous  product,  its  absorption  or  deg- 
radation, and  the  formative  processes  (by  fibrosis,  ebur- 
nation,  etc.)  already  studied.     As  a  consequence  of  these 


SYPHILIS   OF   THE   EAR.  1 95 

changes  in  the  orbital  bones,  exophthalmos  (protrusion 
of  the  eyeball  outward,  along  its  axis,  or,  as  is  not  un- 
common, to  one  side)  may  result,  with  secondary  con- 
sequences due  to  stretching  and  traumatism  of  the  optic 
nerve.  In  other  cases  the  nerve  is  injured  by  pressure, 
and  atrocious  neuralgias  may  follow.  In  yet  other  cases 
abscesses  form  and  burst  externally,  at  times  with  result- 
ing exfoliation  of  osseous  sequestra,  at  others  with  the 
formation  of  fistulous  tracts  leading  to  carious  bone. 
When  exostosis  occurs  from  the  walls  of  the  orbit,  the 
tumor  usually  forms  on  the  inner  wall  and  projects 
toward  the  central  axis ;  but  it  may  also  develop  near 
the  apex  and  produce  exophthalmos  or  grave  pressure- 
effects.  These  growths  as  a  result  of  syphilis  are  ex- 
tremely rare. 

Syphilis  of  the  Ear. 

The  auricle  may  be  the  seat  of  chancre  (usually  as  the 
result  of  a  bite)  or  of  any  of  the  cutaneous  lesions  of 
systemic  syphilis — macules,  papules,  pustules,  tubercles, 
gummata,  ulcers,  etc. 

The  meatus  may  also  be  found  affected  with  any  of 
the  lesions  occurring  upon  the  auricle.  Exceedingly 
intractable  ulcerations  occasionally  progress  just  within 
the  meatus,  at  the  junction  of  cartilage  and  bone.  These 
ulcers  greatly  resemble  the  ill-conditioned  ulcers  often 
visible  at  the  same  time  and  in  the  same  patient  just 
within  the  nares.  Condylomata  are  not  rare  within  the 
meatus,  where  they  may  often  be  recognized  as  circum- 
scribed, scaling  elevations  of  the  surface,  furnishing  an 
admixture  of  pus  and  cerumen,  in  extreme  cases  event- 
ually inducing  by  their  presence  a  typical  otitis  externa. 
Blocking  of  the  canal  may  ensue,  and  in  severe  cases 
ulceration  with  scarring.  Rarely  there  results  per- 
manent  contraction   of  the   meatus. 

The  membrana  tympani  is  rarely  the  seat  of  syphilitic 
lesions.  Luetic  changes  have,  however,  been  recognized 
in  this  situation,  and   ulceration  has  at  times  resulted 


I96       SYPHILIS  AND    THE    VENEREAL   DISEASES. 

from  degeneration  of  minute  gummata  situated  upon  the 
drum. 

The  diseases  of  the  tympanum  due  to  syphilis  are 
obscured  by  reason  of  the  difficulty  experienced  in  pre- 
cisely locating  any  lesions  capable  of  producing  the 
symptoms  exhibited  in  any  given  case,  and  by  the 
further  fact  that  the  symptoms  presented  are  so  nearly 
alike  in  the  victims  of  both  syphilitic  and  non-syphilitic 
aural  disease. 

Catarrhal  inflammatory  affections  of  the  middle  ear 
occur,  resulting  in  hypersecretion,  pus-formation,  or  the 
formation  of  plastic  products,  the  distinction  between 
these  affections  being  established  by  symptoms  rather 
than  by  any  recognized  lesions.  Most  of  these  troubles 
are  associated  with  or  spring  directly  from  disorders  of 
the  naso-pharynx,  which  is  so  frequently  involved  in 
systemic  syphilis ;  others  arise  from  changes  in  the 
osseous  walls  of  the  Eustachian  tube  or  from  periostitis 
of  the  tympanum.  The  symptoms  of  these  diseases  of 
the  middle  ear  are  chiefly  deafness  in  varying  degrees, 
pain,  serous  or  purulent  discharges,  tumefaction  to  the 
point  of  obstruction  of  the  Eustachian  tube,  and  rales  on 
its  insufflation. 

The  changes  in  the  labyrinth  due  to  syphilis  are  as 
yet  little  understood.  The  ossicles  may  be  ankylosed, 
and  all  the  tissues  composing  the  labyrinth  may  be 
thickened  either  primarily  or  as  a  result  of  extension  of 
disease  from  the  tympanum.  The  symptoms  are  found 
in  a  series  of  widely  differing  subjective  sensations  of  a 
morbid  character,  associated  with  imperfect  audition, 
diminution  of  bone-conduction,  and  vertigo  often  re- 
sembling that  occurring  ab  aare  Iceso. 

HEREDITARY  SYPHILIS. 
Syphilis  may  be  transmitted  from  progenitor  to  off- 
spring as  a  strictly  inherited  disease.     The  term  "  con- 
genital "  has  been  somewhat  loosely  applied  by  different 
writers  either  to  inherited  syphilis  or  to  syphilis  acquired 


HEREDITARY  SYPHILIS.  1 97 

at  birth  of  an  infant  and  due  to  infection  from  recently- 
developed  chancres  of  the  maternal  passages.  In  these 
pages  the  term  "  hereditary  syphilis "  is  employed  to 
designate  exclusively  the  disease  acquired  by  inherit- 
ance. The  term  "  congenital,"  as  liable  to  beget  con- 
fusion, should  be  dropped  from  the  nomenclature. 

A  vast  amount  of  discussion  has  been  elicited  by 
questions  concerning  the  etiology  of  inherited  syphilis. 
It  is  sufficient  here  merely  to  state  that,  for  most  cases, 
the  fact  of  a  syphilitic  child  points  to  inheritance  from 
the  mother.  When  the  father  is  without  question 
syphilitic,  and  children  are  born  syphilitic,  the  mother, 
free  from  all  evidences  of  the  disease,  has  probably 
been  infected.  She  betrays  no  evidences  of  this  infection 
either  because  at  the  date  of  observation  syphilitic 
symptoms  previously  exhibited  have  disappeared,  or 
because  the  proofs  of  her  morbid  state  are  to  be  sought 
exclusively  in  the  fruit  of  her  several  pregnancies  and 
in  the  striking  fact  that  she  is  incapable  of  infection  by 
her  syphilitic  offspring,  according  to  the  law  of  Colles, 
given  on  page   198. 

The  apparently  healthy  mothers  who  give  a  history 
of  a  succession  of  abortions,  miscarriages,  and  birth  of 
infected  children  due  to  syphilis  can  to-day  be  grouped 
in  a  class  well  recognized  by  every  expert.  It  can- 
not always  be  determined  whether  such  women  have 
been  infected  with  syphilis  directly  from  the  husband, 
as  has  been  claimed,  or  indirectly  from  the  syphilitic 
contents  of  the  uterus.  These  mothers  may  even  be  in 
generally  poor  health,  ansemic,  weak,  and  debilitated,  or 
they  may  exhibit  every  evidence  of  sound  health,  being 
vigorous,  brawny,  red-cheeked,  and  with  all  their  func- 
tions duly  performed.  In  these  instances,  without  ques- 
tion, the  syphilitic  symptoms  consist  of  the  fruit  of  a 
series  of  conceptions.  Just  as  syphilis  of  the  healthy 
adult  in  some  of  its  stages  limits  itself  definitely  to  a 
persistent  or  recurrent  patch  of  tubercles  on  the  buttock 
or  on  a  hand,  so  in  these  apparently  healthy  women  the 


I98      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

disease  limits  itself  absolutely  to  the  symptoms  exhibited 
— a  diseased  ovum,  foetus,  or  infant,  frequently  several 
of  each  in  a  single  history.  When,  however,  the  mother 
is  without  question  exempt  from  the  suspicion  of  syphi- 
lis, and  the  father  is  as  surely  syphilitic,  the  child  in- 
variably escapes.  Cases  of  such  absolute  exemption  on 
the  part  of  the  mother  are  those  where,  the  father  being 
assuredly  the  subject  of  the  disease,  the  mother  has 
never  had  an  abortion,  a  miscarriage,  a  diseased  child, 
or  any  other  symptom  of  the  disease,  and  exhibits  all 
the  evidences  of  sound  health. 

Colles's  law,  first  formulated  in  1837  by  Abraham 
Colles  of  Dublin,  embodies  the  well-known  fact  that, 
although  it  is  admitted  that  the  mouth  of  a  syphilitic 
infant  is  infectious  for  every  other  person,  no  mother  of 
such  a  child  was  ever  given  syphilis  by  her  own  off- 
spring. No  woman  ever  had  a  chancre  of  the  nipple 
result  from  frequent  contacts  with  the  infectious  secre- 
tions of  her  child's  mouth.  This  law,  the  reported  ex- 
ceptions to  which  are  so  few  and  so  poorly  established 
as  to  be  worth  nothing  in  the  way  of  refutation,  points 
conclusively  to  the  fact  above  stated,  that  syphilis  of 
the  child  always  points  to  syphilis  of  the  mother,  either 
present  or  past,  revealed  by  unquestioned  symptoms 
or  by  a  series  of  syphilitic  conceptions  betrayed  as 
such  by  the  occurrence  of  abortions,  miscarriages,  still- 
births, and  infected  offspring. 

The  period  of  pregnancy  beyond  which  the  mother 
cannot,  even  if  infected,  transmit  her  disease  to  her  un- 
born child  is  not  fixed.  It  is  probable  that  with  different 
patients  the  period  changes,  the  differences  being  due  to 
the  general  health  of  the  mother  and  to  her  aptitude  or 
inaptitude  for  furnishing  favorable  ground  for  the  propa- 
gation of  the  toxines  of  the  disease.  After  the  sixth 
month  the  child  probably  escapes ;  but  even  so  late  as 
the  seventh  or  eighth  month,  if  the  mother  be  infected, 
there  is  risk  to  the  foetus. 

There  have  arisen  in  connection  with  this  subject  a 


HEREDITARY  SYPHILIS.  1 99 

few  unimportant  questions,  the  responses  to  which  are 
by  no  means  trustworthy.  No  man,  in  fact,  can  study  the 
literature  of  the  etiology  of  inherited  syphilis,  and  have 
had  experience  of  the  disease  in  both  public  and  private 
practice,  without  realizing  the  possibilities  of  error,  in  any 
given  case,  respecting  the  fact  of  parental  disease  and  of 
error  arising  from  the  infective  accidents  common  in  the 
modern  social  life  of  large  towns.  Especially  is  this 
the  case  since  the  date  of  recognition  of  the  practically 
innumerable  opportunities  for  accidental  infection  af- 
forded by  the  medium  of  utensils,  instruments,  and  the 
contacts  of  professional  and  domestic  service.  Thus,  a 
child  (born  of  a  syphilitic  woman)  reported  to  be  after 
birth  the  victim  of  an  initial  sclerosis,  followed  by  signs 
of  acquired  disease,  has  almost  certainly  been  infected  by 
some  accident  after  birth,  and  was  free  from  inherited 
disease  when  born.  The  question  also  whether  inherited 
syphilis  can  be  transmitted  to  a  third  generation  can  for 
the  immense  majority  of  all  cases  be  answered  in  the 
negative,  the  exceptions  reported  being  not  always 
thoroughly  purged  of  the  suspicion  of  accidental  in- 
fection. No  expert  fails  to  observe  at  intervals  cases 
of  supposed  "  inherited  disease "  where  a  rigid  and 
carefully  conducted  examination  demonstrates  that  the 
disease  was,  as  a  matter  of  fact,  acquired ;  and  the  chil- 
dren of  such  patients,  really  suffering  from  acquired 
syphilis  and  not  from  an  inherited  malady,  would  readily 
be  assumed  to  represent  a  transmission  of  hereditary 
lues  to  a  third  generation.  The  question  respecting 
acquisition  of  syphilis  later  in  life  by  the  subject  of  in- 
herited disease  is  to  be  answered  with  the  same  caution 
and  reserve.  Certain  it  is  that  syphilis  in  a  few  cases, 
after  it  is  acquired,  does  not  wholly  protect  its  victim 
from  a  second  attack  of  the  same  disease.  We  have 
already  seen  that  these  subjects  of  infection  will  occasion- 
ally, after  exposure  to  initial  scleroses,  suffer  from  sin- 
gular and  occasionally  severe  local  ulcerations,  simulat- 
ing new  initial  scleroses,  even  at  times  with  adenopathy 


200      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

of  the  neighboring  glands,  the  prior  infection,  though 
preventing  a  new  syphilis,  being  apparently  insufficient 
to  protect  against  local  reinfection.  The  cases  here  con- 
sidered are  not,  of  course,  of  the  class  where  gum- 
matous deposits  occur  in  the  genital  region  of  the  in- 
fected at  the  site  of  merely  local  irritation.  This  reason- 
ing applies  with  special  force  to  the  rare  cases  reported 
in  which  a  syphilis  derived  from  progenitors  whose  virus 
has  been  attenuated,  presumably,  in  a  score  or  more  of 
years,  loses  at  last,  in  the  second  generation,  its  power  to 
furnish  immunity  against  reinfection. 

Syphilis  of  the  Placenta. — The  placenta  may  exhibit 
signs  of  syphilis  after  the  foetus  has  become  the  subject 
of  unmistakable  symptoms  of  the  same  disease.  Many 
of  the  placental  changes  recorded  by  authors  are  un- 
doubtedly confused  with  those  occurring  in  non-syphi- 
litic processes,  and  there  is  no  basis  for  assuming  of  this 
viscus  that  it  differs  from  others  in  that  its  lesions  in  the 
subject  of  syphilis  are  wholly  due  to  the  infectious  dis- 
ease present. 

In  some  cases  of  undoubted  syphilis  of  the  offspring 
the  placenta  has  been  found  wholly  free  from  morbid 
symptoms,  while  at  other  times  an  endometritis  placen- 
taris  occurs,  in  which  dense  nodules  are  found  in  a  volu- 
minous, dense,  and  otherwise  deformed  organ,  with  a 
whitish  fibrous  capsule  and  a  central  mass  composed 
either  of  clusters  of  spindle-cells  proceeding  from  the 
blood-vessels,  or  of  degenerating  softish  masses  of  a 
yellowish-white  hue.  With  these  gummata  are  masses 
representing  transformed  villi — hyperplastic,  compressed, 
thickened,  agglutinated,  or  even  wholly  destroyed. 
Atheromatous  and  other  metamorphoses  involve  the 
vessels  of  the  umbilical  cord,  with  resulting  thickening 
of  the  intima,  thrombosis,  and  even  vascular  oblitera- 
tion. A  result  fatal  to  the  contents  of  the  uterus 
succeeds  an  involvement  in  these  changes  of  the 
larger  portion  of  the  placenta.  When  handled,  the 
placenta    in    well-marked    cases    is    in    parts    firmly  in- 


HEREDITARY  SYPHILIS.  201 

durated,  is  heavier  than  usual,  and  its  lobulations  dis- 
appear. In  some  cases  circumscribed  gummata  may 
be  detected  by  palpation  of  the  mass,  which,  when  in- 
cised, discloses  grayish-yellow  nodules  with  a  fattily 
changed  centre.  Efforts  to  diagnosticate  syphilis  as 
derived  from  either  the  father  or  the  mother  by  recogni- 
tion of  changes  in  the  placenta  are  apt  to  lead  to  un- 
trustworthy conclusions. 

It  is  a  matter  of  importance  to  note  that  the  liquor 
amnii  of  the  woman  bearing  a  syphilitic  foetus  is  capable 
of  communicating  the  disease  to  an  accoucheur. 

Symptoms  of  Hereditary  Syphilis.  —  One  of  the 
earliest  and  most  frequent  symptoms  of  syphilis  in  the 
product  of  conception  is  death  of  the  ovum  or  foetus ;  and 
in  a  number  of  consecutive  conceptions  these  symptoms 
often  become  conspicuous  in  a  series  of  accidents  of  the 
same  character.  Thus,  a  woman  infected  by  her  hus- 
band soon  after  marriage  may  have  a  series  of  preg- 
nancies, covering  a  number  of  years,  in  which  abortions 
occur,  first  at  an  earlier  and  later  at  a  more  advanced 
stage  of  gestation,  these  succeeded  by  one  or  more  mis- 
carriages, and  the  latter  by  the  birth  of  a  mature  child 
surviving  but  a  few  hours.  Eventually  a  child  may 
be  born  apparently  healthy  at  birth,  but  developing 
before  the  fourth  month  symptoms  of  inherited  syphilis. 
Even  after  a  series  of  such  pregnancies  there  may  at 
last  be  brought  into  the  world  a  healthy  child  who  never 
exhibits  signs  of  constitutional  disease.  The  mortality 
in  these  cases  falls  between  60  and  90  per  cent. 

About  seven-eighths  of  diseased  infants  exhibit  symp- 
toms of  the  inherited  malady  before  the  termination  of 
the  third  month.  Of  the  remaining  eighth  a  certain 
proportion  have  actually  exhibited  symptoms  either 
ignored  or  misunderstood.  A  small  but  unknown  pro- 
portion betray  evidences  of  transmitted  disease  at  a  date 
between  the  fourth  month  and  the  close  of  the  first  year 
of  life.  Cases  were  once  reported  of  so-called  "  late  " 
inherited  syphilis  in  which  the  symptoms  of  the  disease 


202      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

were  supposed  to  be  first  displayed  at  or  about  the 
puberal  epoch  ;  but  there  are  few  physicians  who  do  not 
look  with  suspicion  on  such  reports.  It  is  believed,  not 
without  good  reason,  that  the  most  of  such  patients  really 
betrayed  evidences  of  syphilis  in  infancy,  but,  as  occurs 
so  often  in  acquired  cases,  such  symptoms  were  over- 
looked or  were  assigned  to  the  indefinite  category,  often 
misinterpreted,  of  "  children's  disorders."  Cases  of  bone 
disease  in  adults  known  to  have  syphilitic  parents,  the 
osseous  lesions  first  appearing  in  the  second  generation 
after  the  twenty-fifth,  the  thirtieth,  the  fortieth,  and  even, 
as  reported  in  one  case,  after  the  sixtieth  year,  are  in 
general  to  be  accepted  with  great  reserve. 

Cutaneous  Lesions  of  Hereditary  Syphilis. — When 
miscarriages  occur  as  a  result  of  inherited  disease, 
the  fcetus  has  often  perished  some  days  before  its  ex- 
pulsion, and  its  skin  is  then  usually  macerated  and,  in 
consequence  of  the  feeble  union  between  the  epidermis 
and  the  corium,  raised  here  and  there  in  bullae,  usually 
flaccid  and  filled  with  an  ill-conditioned  serum.  This 
condition  is  often  improperly  termed  "  syphilitic  pem- 
phigus." In  other  cases  there  is  born  a  viable  child 
with  a  specific  exanthem  either  affecting  one  region  (for 
example,  the  palms  and  the  soles)  or  extensively  and 
even  generally  evolved.  In  yet  other  cases  the  new- 
born infant  may  present  at  birth  all  the  evidences  of 
sound  health,  and  at  a  later  date,  before  the  close  of  the 
third  month,  may  develop  insidiously  the  symptoms  of 
cutaneous  disease.  Every  practitioner  is  suspicious  of 
an  infant  born  into  the  world,  even  though  living,  con- 
siderably under  the  average  weight,  weazened,  yellow- 
tinted,  and  snuffling,  with  the  appearance  of  a  "  little 
old  man  "  or  a  "  little  old  woman,"  and  exhibiting  one 
or  several  "  blisters  "  on  the  fingers  or  the  toes.  The 
appearance  of  premature  senility  in  these  weazened  and 
speckled  infants,  with  a  flaccid  skin  which  may  be  gath- 
ered between  the  fingers  like  that  of  some  of  the  lower 
animals,  with  a  circlet  of  papules  about  the  anus  or  the 


Plate  18. 


Papulo-pustular  exanthem  of  hereditary  syphilis  (Mracekj 


Ltih,  Anst  F.  Reichhold.  Minchen. 


HEREDITARY  SYPHILIS.  203 

mouth,  with  peculiar  wrinkles  extending  laterally  from 
the  oral  commissures,  with  a  feeble  stridulous  cry,  and 
with  obvious  weakness,  is  often  sufficient  to  enable  one 
to  establish  the  diagnosis  at  a  glance. 

A  macular  syphilodcrm  in  these  infants  has,  in  general, 
the  shade  observed  in  acquired  cases,  the  difference 
being  chiefly  the  larger  size  of  the  individual  spots,  their 
more  pronounced  shade,  varying  from  a  dull  red  to  an 
empurpled  hue,  and  their  tendency  to  desquamate  and 
secrete  in  regions  of  friction,  pressure,  and  moisture. 
The  color  in  some  feeble  and  weazened  children  is  a 
characteristically  dirty  brown,  rarely  imitated  in  any 
non-syphilitic  infant.  This  exanthem  may  disappear  or 
recur  or  be  followed  by  others  of  a  graver  type. 

The  papular  syphiloderm  of  inherited  disease  is  rarely 
as  generalized,  as  dry,  or  constituted  of  as  small-sized 
individual  lesions  as  the  corresponding  eruption  of 
acquired  disease.  In  the  infant,  papules  are  apt  to  be 
grouped  about  portions  of  the  face,  of  the  trunk,  or  of 
the  limbs;  are  often  seated  upon  a  hyperaemic  base;  are 
in  general  distinctly  grouped;  and  usually  tend  to  co- 
alesce and  become  flattened,  scaling,  or,  in  regions  of 
moisture,  friction,  and  pressure  (as  about  the  anus  and 
the  vulva),  to  secrete  freely.  In  point  of  fact,  the 
necessity  of  constantly  applying  napkins  over  the  ano- 
genital  region  of  infants,  and  the  frequency  with  which 
(in  the  case  of  syphilitic  infants  especially)  the  accumu- 
lation of  faeces  and  urine  on  these  articles  of  clothing  is 
permitted,  make  this  region  one  in  which  the  lesions  of 
the  disease  are  apt  to  be  displayed  not  only  often  but 
in  largest  evolution.  It  is  always  incumbent  upon  the 
cautious  practitioner  to  inspect  the  anal  region  of  infants 
exhibiting  an  exanthem  about  which  any  suspicion  is 
entertained. 

Often  the  circular  outlines  of  groups  of  papules  in 
hereditary  disease  is  exceedingly  distinct,  the  central 
portions  of  the  enclosed  area  being  apparently  unaf- 
fected.    These  rings  or  portions  of  rings  may  be  seen 


204      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

clustered  about  one  angle  of  the  mouth,  where  cracks 
may  form  in  the  angle  itself,  or  about  the  buttock,  or 
over  the  palmar  and  plantar  regions. 

Condylomata,  as  has  been  shown  in  connection  with 
acquired  syphilis,  represent  merely  flattened  papules  oc- 
curring in  sites  of  the  body  especially  moist  and  warm  and 
subjected  either  to  friction  or  to  the  pressure  of  apposed 
surfaces.  In  hereditary  syphilis  condylomata  are  most 
often  encountered  about  the  anus,  where  they  may  be 
recognized  as  hypertrophic  papules,  flattened,  at  times 
fissured  and  excoriated,  often  secreting  apuriform  mucus, 
grayish- white,  pinkish-white,  or  even  brownish  in  hue. 
They  may  be  few  or  exceedingly  numerous.  In  infants 
long  kept  in  contact  with  the  breast  they  may  exhibit 
characteristic  features  near  the  angles  of  the  mouth. 

Pustular  and  furuncular  lesions  in  hereditary  syphilis 
may  occur  as  early  or  late  manifestations  of  the  disease 
— that  is,  within  a  few  months  after  birth  or  during  the 
second  year.  Like  the  pustules  of  acquired  disease, 
they  represent  infective  processes  upon  a  soil  rendered 
apt  for  such  infection  by  the  systemic  disorder.  The  pus- 
tules are  commonly  in  groups,  deep-seated,  livid-red  in 
hue,  and  with  deeply  set  base.  They  linger  by  prefer- 
ence about  the  mucous  outlets  of  the  body,  but  may  also 
be  seen  on  the  palms  and  soles  and  over  the  limbs. 
When  they  burst  they  are  speedily  covered  with  a  char- 
acteristic crust  of  dirty  aspect,  beneath  which  ulceration 
may  progress.  The  subjective  sensations  produced  are 
those  of  burning  and  itching.  Furuncular  and  furuncu- 
loid  lesions  may  spring  from  pustules  or  begin  as  multi- 
ple circumscribed  abscesses  coincident  or  in  successive 
crops.  They  are  usually  exceedingly  indolent,  and  when 
bursting  leave  crateriform  cavities  behind,  in  consequence 
of  the  ill-conditioned  slough  which  is  cast  from  the  centre 
of  each  depot. 

Bidlons  lesions  in  inherited  syphilis  are  not  rare,  and 
commonly  betoken  grave  conditions  of  the  system. 
They  may  exist  at  the  moment  of  birth  of  the  dead  or 


Plate  19. 


/o 


u 


HEREDITARY  SYPHILIS.  205 

the  living  child,  or  they  may  afterward  develop  as  pin- 
head-  to  bean-sized  and  larger  elevations  of  the  epider- 
mis, filled,  as  a  rule,  with  an  ill-conditioned  sero-pus  or 
blood,  having  an  inflammatory  areola  of  dirty  hue,  and 
followed,  after  bursting  and  release  of  their  contents,  with 
blackish,  greenish,  and  dirty-yellowish  crusts.  The 
palms  and  the  soles,  as  also  the  digits  of  either  hands 
or  feet  or  both,  may  be  the  seat  of  these  lesions,  which 
may  be  followed  by  ill-conditioned  ulcers. 

Tubercles  in  inherited  syphilis  are  usually  multiple, 
deeply  seated,  and  grouped,  and  they  soon  undergo 
degeneration.  They  often  precede  a  condition  in  which 
form  greenish-black  sloughs,  ulcers  spreading  deeply 
beneath. 

The  forms  of  hemorrhagic  syphilis  described  by  authors 
include  those  in  which  severe  umbilical  hemorrhage 
occurs  at  or  soon  after  birth,  as  also  the  cases  in  which 
bullous  lesions  become  filled  with  blood,  and  those  in 
which  distinctly  purpuric  blotches  spread  sparsely  or  in 
large  numbers  over  the  integument.  Some  of  these 
forms  are  undoubtedly  not  to  be  distinguished  from 
haemophilia. 

Vesicular  syphilodermata  are  described,  in  connection 
with  hereditary  syphilis,  as  predecessors  of  a  pustular  or 
bullous  exanthem,  the  lesions  being  minute  vesicles  filled 
with  a  transparent  serum  closely  packed  together,  form- 
ing about  the  face,  the  extremities,  or  the  trunk.  Doubt 
is  thrown  upon  such  eruptions,  chiefly  because  vesicula- 
tion  usually  points  to  a  pathologic  process  more  rapid 
in  its  course  than  syphilis,  and  also  because  intercurrent 
disorders  are  so  apt  to  produce  vesiculation  in  an  infant's 
skin.  Among  these  disorders  may  be  named  profuse 
sweating  (sufficiently  common  in  infancy),  drugs  ingested 
for  the  relief  of  the  syphilis  present,  and  the  several  forms 
of  dermatitis,  eczema,  and  exanthemata  to  which  children 
of  a  tender  age  are  specially  prone. 

The  mucous  membranes,  in  inherited  as  in  acquired  dis- 
ease, display  bullous  lesions,  papules,  tubercles,  mucous 


206      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

patches,  and  even  pustules.  These  several  lesions  in 
the  profound  dyscrasic  state  of  weakly  infants  often 
rapidly  degenerate  into  the  most  formidable  ulcerations. 
By  the  presence  of  the  secretions  which  are  abundantly 
furnished  in  children,  and  desiccated  readily  by  the  cur- 
rents of  air  when  the  mouth  is  kept  open  habitually  in 
the  Weak  state  of  the  child,  the  nares  become  blocked 
by  an  obstructive  rhinitis,  and  the  respiratory  tract,  par- 
ticularly of  the  larynx  and  of  the  trachea,  is  greatly  en- 
cumbered. In  this  way  arise  the  catarrhal  symptoms — 
the  peculiar  "  snuffles  "  of  the  syphilitic  baby,  its  feeble 
and  stridulous  voice,  the  necessity  of  abandoning  its 
grasp  of  the  mother's  nipple  in  order  to  breathe  and  to 
cry, — all  marked  characteristics  of  the  disease  in  the 
new-born  of  the  second  generation.  In  advanced  stages 
of  involvement  of  the  mucous  surfaces  the  respiration 
becomes  seriously  impeded  when  there  is  unusual  effort 
of  any  sort.  When  no  special  effort  is  made  the  child 
lies  listless  in  its  mother's  lap  or  arms,  with  pinched,  sal- 
low features,  its  limbs  flaccid  and  extended,  and  its  ex- 
pression indescribably  apathetic.  At  any  time  during 
the  evolution  of  the  symptoms  here  described  an  inter- 
current disorder  (pneumonia  of  a  low  grade,  an  incoerci- 
ble  diarrhoea,  or  a  progressive  marasmus)  may  bring  on 
a  fatal  termination.  The  respiratory  tract  as  far  as  the 
bronchi  is  much  more  readily  involved  in  infantile  than 
in  acquired  disease. 

By  far  the  most  common  of  the  several  affections  of 
the  mucous  membrane  is  the  mucous  patch  of  the  mouth, 
which  strongly  resembles  the  similar  lesion  of  acquired 
disease.  The  patches  are  usually  circumscribed,  slightly 
elevated,  and  well-defined  opalescent  plaques,  with  a  red- 
dened areola,  which  may  coalesce,  forming  thus  large 
areas  of  involvement ;  which  may  hypertrophy,  and  thus 
come  to  resemble  condylomata ;  or  which  may  break 
down  by  ulceration  and  be  covered  with  a  diphtheroid  or 
pultaceous  slough.  It  is  a  matter  of  importance  to  note 
that  these  lesjons  in  hereditary  syphilis  are  quite  as  con- 


HEREDITARY  SYPHILIS.  207 

tagious  as  in  the  acquired  form  of  the  disease;  and  as  the 
practice  of  kissing  infants  and  of  putting  them  to  the 
breasts  of  other  women  than  their  own  mother,  and  even 
of  inserting  into  the  mouth  of  a  nurse  or  attendant  a 
spoon  which  has  been  made  the  vehicle  of  conveying  food 
to  the  diseased  mouth  of  the  child,  is  sufficiently  common, 
the  corollary  is  obvious.  There  are  few  syphilographers 
who  cannot  recount  a  sad  list  of  histories  of  the  innocent 
victims  of  syphilis  infected  by  a  child. 

Gummatous  infiltrations  of  mucous  membranes  are 
usually  later  of  development  than  mucous  patches,  occur- 
ring in  the  third  year  and  afterward,  as  circumscribed, 
prominent,  roundish  or  oval  patches,  often  seen  upon  the 
hard  palate  or  over  the  posterior  wall  of  the  pharynx. 
They  may  degenerate  to  form  exceedingly  rebellious,  and 
even  formidable,  ulcers,  especially  upon  the  pharyngeal 
wall,  which,  aiter  healing,  may  leave  cicatrices  of  a  de- 
forming and  obstructive  character. 

The  nails  are  involved  in  inherited  disease  both  pri- 
marily and  as  a  result  of  changes  in  the  nail-fold,  the 
matrix,  or  the  bed.  When  primarily  affected,  any  one 
of  the  lesions  named  above  may  appear  and  be  followed 
by  suppuration  or  ulceration,  with  shedding  of  the  nail ; 
or  the  nail-plate  may  become  dry,  fissured,  "  worm- 
eaten,"  yellowish,  crumbling,  or  in  various  degrees  dis- 
torted, or  it  may  suddenly  be  shed. 

The  onychia  may  be  either  of  the  ulcerative  or  the 
non-ulcerative  type.  The  former  begins  by  the  produc- 
tion of  a  papulo-pustule  at  the  border  of  the  nail-plate, 
which  results  in  an  ulcer  sweeping,  as  a  rule,  along  the 
nail-fold,  at  times  invading  the  matrix.  The  resulting 
ulcer,  in  these  cases,  is  a  characteristic  lesion,  with  sloughy 
floor,  everted  margin,  and  sero-purulent  discharge  cap- 
ping a  spade-shaped  phalanx.  In  some  cases  the  pha- 
langeal bone  becomes  involved.  In  the  non-ulcerative 
form  of  the  disease  there  are  onychogryphosis  of  the 
nail-plate  and  considerable  tumefaction  of  the  surround- 


208       SYPHILIS  AND    THE    VENEREAL   DISEASES. 

ing  parts,  which  take  on  a  characteristic  dull  reddish- 
brown  hue. 

The  hairs  in  hereditary  syphilis  fall  as  in  acquired 
disease,  and  this  either  before  or  after  the  birth  of  the 
infant.  The  loss  may  be  partial  or  complete,  and  if 
partial  may  consist  either  of  a  thinning  of  the  hairs  in 
one  region  or  of  their  removal  en  masse  from  definite 
areas,  circular,  irregularly  shaped,  or  in  ribbon-like 
stripes.  Often  these  pilary  losses  are  directly  dependent 
upon  structural  changes  in  the  scalp,  due  to  pustulation, 
gummata,  or  the  production  of  tubercles.  Usually  the 
scalp  is  chiefly  involved. 

The  lymphatic  vessels  and  glands  exhibit  changes  due 
to  inherited  syphilis,  notably  by  signs  of  engorgement, 
infiltration,  and  enlargement ;  suppuration  is  a  common 
result  of  such  changes.  The  thymus  is  chiefly  involved, 
but  all  the  thoracic  and  abdominal  glands  may  be  impli- 
cated, including  the  parotid,  the  inguinal,  and  the  axillary. 

The  genital  organs  of  both  sexes  may  be  attacked,  the 
penis  and  the  testicles  of  male  infants  (epididymis  and 
testes)  especially.  In  both  sexes  the  generative  organs 
may  be  undeveloped,  approaching  in  appearance  the  rudi- 
mentary type. 

In  our  experience,  epididymitis  and  orchitis,  the  former 
often  a  complication  of  the  latter,  are  symptoms  of  in- 
herited lues  in  male  subjects  more  common  than  is  gen- 
erally supposed.  We  have  determined  the  existence  of 
these  lesions  in  so  many  cases  where  the  parents  of  the 
child  have  been  wholly  ignorant  of  the  fact,  and  in  a  few 
cases  of  inherited  disease  after  the  close  of  the  first 
decade  where  the  subject  of  the  malady  himself  had  no 
knowledge  of  the  testicular  affection,  that  we  believe  the 
point  to  be  one  of  importance.  The  exceedingly  insid- 
ious evolution  of  the  changes  in  the  organ,  the  frequent 
absence  of  subjective  sensations,  and  the  absence  of  func- 
tion at  a  tender  age,  account  sufficiently  for  the  ignoring 
of  the  complication  in  many  cases. 

As   a   rule,  the  first   symptoms  are  made  obvious  on 


HEREDITARY  SYPHILIS.  20g 

examination  between  the  first  and  the  fifteenth  year  of 
life,  although  the  recorded  limits  are  the  third  week  and 
the  twenty-fifth  year.  At  first,  firm,  pea-sized  masses 
may  be  felt  in  the  epididymis  or  testis  proper,  or  in  both, 
as  early  as  the  date  of  first  examination.  In  our  experi- 
ence it  is  common  to  find  both  sides  attacked  simulta- 
neously. The  lesions  are  usually  smooth,  painless,  firm, 
homogeneous,  roundish  swellings.  Occasionally  the  vas 
deferens  is  involved ;  at  times  pain  is  elicited  on  pressure. 
Atrophy,  resolution  under  treatment,  very  rarely  "  fun- 
gus "  of  the  testicle,  may  result.  There  may  be  an  accom- 
panying hydrocele.  We  have  never  seen  a  case  in  which 
there  seemed  to  be  the  slightest  probability  of  preserva- 
tion of  the  function  of  the  organ  on  reaching  maturity. 

The  diagnosis  from  tuberculosis  is  often  a  matter  of 
moment.  The  syphilitic  testis  may  be  single  instead  of 
double  ;  tuberculosis,  on  the  other  hand,  may  involve 
both  sides.  The  condition  of  the  prostate  gland  and  vesi- 
cles must  always  be  carefully  investigated,  in  order  to 
determine  the  facts.  Usually  a  knot  in  one  testis  corre- 
sponds in  tuberculosis  with  a  knot  in  the  prostate  on  the 
same  side.  At  times,  however,  the  advance  of  tubercu- 
losis upward  in  the  male  genital  tract  may  be  in  the 
shorter  circuit,  from  side  to  side.  Sarcoma  and  cancer 
(e.  g.,  the  "  chimney-sweeps'  cancer  "  of  English  authors) 
must  be  differentiated  in  every  doubtful  case. 

Pathologically,  the  lesions  are  recognized  as  due  to  a 
circumscribed  or  diffuse  cell-infiltration,  selecting  chiefly 
the  periphery  of  the  smaller  vessels,  usually,  but  not 
always,  starting  in  the  mediastinum  and  travelling  along 
the  lines  of  the  trabeculae  between  the  tubules,  which  are 
finally  obliterated  by  pressure-effect.  Resorption  of  the 
effused  deposit  and  atrophy  are  the  natural  issue.  Gum- 
mata  of  the  type  seen  in  general  in  the  viscera  are  rela- 
tively rare  in  the  testes  in  inherited  syphilis,  but  the  gum- 
matous process  is  evidently  largely  responsible  for  the 
changes  here  described. 

The  bones  are  more  often  involved  in  inherited  than  in 

14 


210      SYPHILIS  AND    THE   VENEREAL   DISEASES. 


acquired  disease,  the  percentage  of  cases  in  which  there 
is  osseous  change  being  over  one-third.  Many  lesions 
of  bone  in  children  are  unrecognized  in  consequence  of 
the  greater  gravity  of  other  symptoms  present.  The 
bones  most  frequently  involved  are  the  tibia,  the  ulna, 
the  radius,  and  other  bones  of  the  extremities,  the  clavi- 
cles, and  the  bones  composing  the  skull.  The  special 
lesions  recognized  are  those  described  under  the  title  of 

osseous  lesions  in  ac- 
quired disease — namely, 
circumscribed  gummata 
of  outer  plates  and  med- 
ullary canal,  periostitis, 
and  rarefying  or  forma- 
tive osteitis.  Caries,  ne- 
crosis, and  the  induction 
of  both  ulceration  and 
osteophytic  growths  are 
not  rare.  These  growths 
at  times  induce  prema- 
ture closure  of  the  fon- 
tanelles,  resulting  event- 
ually in  microcephalic 
idiocy.  These  lesions, 
with  the  others  named, 
when  affecting  bones  in 
contact  with  important 
nervous  cells  or  trunks, 
may  induce  all  the  phenomena  of  nervous  syphilis, 
cephalalgia  with  nocturnal  distress,  paralytic  symptoms, 
epileptiform  seizures,  remediless  surdity,  and  even  im- 
becility. 

The  hyperostoses  of  the  tibia  (occasionally  of  both 
tibiae)  produce  at  times  a  highly  characteristic  change  in 
the  contour  of  the  legs.  Marked  anterior  convexity 
results  from  an  osteophytic  growth  along  the  crest, 
which  has  been  termed  by  the  French  "  sabre-blade  de- 
formity" {lame  de  sabre)   (Fig.  8).        Frightful  ravages 


Fig.    8. — Sabre-blade  deformity  of  the 
tibiae  in  hereditary  syphilis. 


HEREDITAR  Y  S  YPHILIS.  2 1 1 

occur  also  in  the  face,  which  may  be  converted  into  a 
wide  area  of  destructive  processes,  the  orbits  half  dis- 
tended with  shrunken  and  sightless  globes,  the  upper  lip 
and  the  maxilla  absent  and  furnishing  the  orifice  of  a 
chasm  composed  of  the  oral  and  nasal  cavities  studded 
with  partly  healed  ulcers  and  fungous  masses. 

The  pseudo-paralysis  of  hereditary  syphilis  produces 
helplessness  of  a  single  member,  due  to  separation  of  the 
epiphysis  from  the  diaphysis  of  one  of  the  long  bones. 
When  unrelieved  for  some  time,  the  ultimate  sequence 
may  be  atrophy  of  the  muscles.  This  epiphyseal  sepa- 
ration is  usually  induced  by  an  osteo-myelitis — a  condi- 
tion to  be  distinguished  from  that  in  which  pseudo- 
ankylosis  results  from  decubitus  and  posture-fixation  in 
consequence  of  grave  disease  of  other  organs  (for  ex- 
ample, a  lower  extremity  after  long-continued  ulceration 
of  a  gummatous  tumor  seated  upon  the  adductor  muscles 
of  the  thigh). 

Fractures  in  bone-syphilis  of  infants  are  not  rare,  but 
it  is  to  be  noted  that  in  these  cases  repair  commonly 
ensues  as  after  fractures  of  the  non-infected. 

Care  should  be  observed,  in  the  diagnosis  of  bone 
disease  in  hereditary  syphilis,  not  to  confound  the  lesions 
with  those  of  osteomalacia  or  rickets,  though  it  has  been 
held  that  the  symptoms  of  the  latter  are  actually  those 
of  syphilis  in  the  second  generation.  In  rickets  the 
bones  are  thinned,  and  not  enlarged  as  in  syphilis,  and 
do  not  show  the  characteristic  bosses  or  nodes  visible 
in  the  skulls  of  many  syphilitic  infants.  In  rickets 
also  the  fontanelles  are  open,  rather  than  closed  pre- 
maturely by  osteophytic  growths ;  the  ribs  are  beset 
with  ridges  or  nodes  ;  and  the  characteristic  symptoms 
of  the  "  knock-knee  "  and  the  protuberant  belly  are  in 
every  well-marked  case  conspicuous.  In  tubercular  and 
other  bone  diseases  of  children  there  is,  of  course, 
exclusion  of  a  history  of  syphilis  in  the  progenitors,  and 
of  abortions  and  still-born  children ;  absence  of  other 
symptoms  of  syphilis ;  a  frequent  limitation  of  the  dis- 


212      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

ease  to  a  single  bone ;  a  tendency  to  the  production  of 
what  is  known  as  "  cold  abscess  ;"  abnormal  thermal 
variations ;  and,  in  the  instance  of  tuberculosis,  the  pos- 
sibility of  the  discovery  of  tubercle  bacilli. 

The  dactylitis  syphilitica  of  inherited  syphilis  scarcely 
differs  from  the  symptoms  of  the  same  affection  in 
acquired  disease.  One  or  several  digits  may  be  in- 
volved, the  changes  occurring  in  the  early  years  of  life. 
The  fall  of  the  distal  phalanges  upon  the  head  of  the 
corresponding' metacarpal  bone  is  usually  highly  sig- 
nificant when  the  proximal  phalanx  has  been  removed 
by  absorption  of  its  mass  ;  and  the  same  is  true  of  the 
oval  tumors  representing  symmetrical  involvement  of  all 
tissues  .surrounding  a  single  phalanx,  with  fistulous 
sinuses  leading  to  carious  bone  or  cartilage  concerned  in 
an  adjacent  joint.  In  some  cases  the  disease  begins  in 
the  joint,  with  symptoms  of  subacute  inflammation  and 
exudation ;  or  the  capsules,  the  tendinous  sheaths,  or 
the  fibrous  tissues  may  be  involved,  with  the  result  of 
producing  a  synovitis  of  more  insidious  development. 
In  yet  other  cases  the  synovial  membrane  thickens 
and  becomes  the  seat  of  overgrowths  simultaneously 
with  the  thickening  of  the  periarticular  tissues. 

The  nasal  passages  in  inherited  syphilis  are  chiefly 
affected  with  a  variety  of  syphilitic  rhinitis  of  purulent 
type,  whose  secretion,  flowing  over  the  lips,  produces 
by  excoriation  a  characteristic  dermatitis.  Infiltra- 
tion of  the  mucous  membrane  lining  the  passage 
results,  as  also  the  obvious  condition  of  "  snuffles " 
already  described.  Sucking,  respiration,  and  phonation 
are  seriously  impeded,  and  in  late  cases  destructive 
effects   upon  the  nasal  and  palatine  bones  may  result. 

The  teeth  in  inherited  syphilis  are  characteristically 
altered,  being,  when  affected,  retarded  in  evolution  and 
imperfectly  formed  in  the  first  dentition,  and  in  the 
second  distorted.  Hutchinson  in  1863  described  changes 
in  the  permanent  teeth  that  are  not  invariably,  but  gener- 
ally, found  in  syphilitic  children  reaching  an  age  when 


HEKEDITA RY  SI PHIL IS. 


213 


the  eruption  of  these  teeth  has  been  accomplished.  The 
central  upper  incisors  are  chiefly  involved,  showing 
semilunar  notches  at  the  free  or  cutting  edge,  these 
teeth  and  others  being  often  also  pegged  and  changed 
in  color  to  a  yellowish  hue  (Figs.  9,  10).  Often  minute 
pits  can  be  detected  in  the  enamel.  These  changes  in  the 
teeth,  when  associated  with  parenchymatous  keratitis  and 
the  scars  of  former  fissures  at  the  angles  of  the  mouth, 


BBhBt      v'v  *■■ 

—  4*.        \^H 

f  w 

■'SsSm 

/ 

.  -.-'^Hl 

.  i  ■:                         MSB 

Fig.    9. — Hutchinson's  teeth  with  osteo-periostitis  and  ulceration  in  inherited  syphilis. 

are   justly  regarded   by  most   physicians   as    pathogno- 
monic of  inherited  syphilis. 

The  pharynx  in  hereditary  syphilis  may  be  the  seat  of 
mucous  patches,  erythematous  blotches,  or  circum- 
scribed or  diffuse  infiltration.  In  exceptional  cases 
verrucous  vegetations  form  on  the  membrane ;  the 
tonsils  become  voluminous ;  ulceration  of  a  superficial 
or  a  deep  character  may  involve  the  submucous  tissue ; 
or  grave  forms  of  stomatitis  supervene,  the  membrane 


214      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

of  the  mouth  exhibiting  on  exposure  an  ashen  look. 
In  patients  of  unusual  debility  hemorrhagic  effusions 
occur.  When  the  bones  are  attacked  the  hard  palate 
may  be  involved,  and,  especially  in  inherited  disease 
which  has  existed  for  some  years,  the  oral  and  nasal 
cavities  are  fused  by  ulcerative  and  destructive  processes 
into  a  single  formidable  chasm.  Often  the  anterior  por- 
tion of  the  nares,  the  upper  lip,  and  the  hard  palate  in 
front  are  merged  in  a  common  ulcerative  fossa.  These 
destructive  results  may  originate  in  either  one  of  the 


Fig.  io. — Hutchinson  teeth. 


two  cavities,  or  in  a  grave  gummatous   involvement  of 
the  skin  of  the  face  followed  by  severe   sloughing. 

The  larynx,  the  trachea,  and  the  bronchi  may  each  be 
the  seat  of  changes  in  inherited  syphilis — infiltrations, 
circumscribed  or  diffuse,  of  the  mucous  or  submucous 
tissues,  followed  or  not  by  ulceration  which  may  destroy 
the  perichondrium  or  the  cartilages.  Here,  as  from  other 
of  the  mucous  surfaces  affected  in  the  disease,  polypiform 
and  verrucous  excrescences  may  spring  from  the  mem- 


HEREDITARY  SYPHILIS.  21 5 

brane,  and  when  situated  in  the  larynx  or  the  trachea 
produce  severe  dyspnoea  and  disorders  of  phonation. 
The  ulcers  of  this  region  differ  but  little  from  those 
exhibited  in  acquired  disease,  being  single  or  multiple, 
and  situated  centrally  or  on  one  or  both  sides  of  the 
larynx.  The  lesions  of  the  trachea  and  the  bronchi  are 
rare  and  are  of  the  same  general  character  as  those  of 
the  larynx. 

Attention  has  already  been  directed  to  the  clinical 
symptoms  dependent  upon  the  changes  here  noted — 
namely,  the  husky  or  stridulous  cry  of  the  infant,  often 
progressively  hoarse  until  wellnigh  complete  aphonia 
results.  The  impairment  of  respiration,  the  frequent 
raucous  cough,  evidently  productive  of  pain  and  taxing 
to  the  utmost  the  strength  of  many  of  these  feeble, 
wailing  infants,  and  the  symptoms  of  dyspnoea,  laryngeal 
spasm,  and  oedema  of  the  glottis,  are  all  significant. 

The  lungs,  when  involved  in  inherited  disease,  exhibit 
changes  in  the  line  of  either  definitely  formed  gum- 
matous deposits  or  of  "  syphilitic  pneumonia,"  the  pro- 
cess then  diffusely  involving  a  large  area  of  a  single  lobe 
or  an  entire  lobe  of  one  lung.  The  tissue  is  firm  on  sec- 
tion, sinks  in  water,  is  grayish  in  hue,  and  its  alveoli  are 
distended  with  swollen  epithelium.  Gummata  of  the 
lungs  are  commonly  miliary  or  lenticular  in  size,  with 
central  necrosis  proceeding  to  fatty  degeneration.  They 
represent  obstructed  and  dilated  alveoli.  These  nodules 
have  a  grayish  hue,  and  they  are  set  in  dense  pulmonary 
infiltrations  of  inflammatory  type.  The  overlying  pleura 
is  usually  thickened  and  opaque.  As  the  process  of 
evolution  is  one  of  alveolar  congestion,  with  peri-bron- 
chial proliferation  and  increase  of  miliary  to  large  filbert- 
sized  yellowish  nodules,  so  the  involutive  process  may 
be  by  fatty  or  caseous  degeneration  or  by  suppuration. 
Complete  restoration  of  an  extensively  involved  syphilitic 
lung  is  occasionally  secured. 

Syphilis  of  the  oesophagus,  of  the  stomach,  and  of  the 
intestinal  tract  is  rather  less  rare  than  in  acquired   dis- 


2l6      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

ease.  In  the  intestines,  especially,  both  definitely  circum- 
scribed and  diffuse  gummatous  infiltrations  have  been 
recognized,  especially  about  Peyer's  patches,  large  and 
single  or  numerous  small  ulcers  resulting.  The  peri- 
toneum may  in  some  cases  participate  in  the  inflammatory 
processes  present.  Whether  the  symptoms  be  recognized 
before  death  (by  palpation  of  the  abdominal  walls  or  by 
a  catarrhal  condition  of  the  bowel)  or  post  mortem, 
agglutination  of  the  intestinal  coils  usually  has  occurred. 

The  pancreas,  when  involved,  is  increased  in  size,  firm, 
and  whitish  on  section.  Between  the  larger  lobules  there 
is  an  overgrowth  of  young  connective-tissue  cells  com- 
pressing the  neighboring  parenchyma  and  resulting  even- 
tually in  the  production  of  lardaceous  degeneration  and 
atrophy.  The  head  of  the  gland  is  most  commonly 
attacked. 

The  liver,  when  involved  in  inherited  syphilis,  may  be 
the  seat  of  circumscribed  or  diffuse  gummata,  set  in  a 
dense  hepatic  mass,  with  obliteration  of  many,  if  not  all; 
of  the  hepatic  capillaries  as  a  result  of  arteritis.  There  is 
commonly  an  odd-looking  marbling  or  mottling  of  the 
hepatic  surface.  The  body  of  the  liver  is  dense,  elastic, 
voluminous,  and  creaks  when  incised.  At  times  the  por- 
tal vein  exhibits  enormous  overgrowth  of  its  connective 
tissue,  choking  its  lumen ;  at  other  times  the  liver-cells 
seem  to  be  compressed  by  a  small-celled  infiltrate  squeez- 
ing the  parenchyma.  The  gummata  may  be  miliary  in 
size  or  as  large  as  filberts,  both  types  having  a  character- 
istic grayish  hue.  This  color  is  not  to  be  confounded  with 
that  of  the  minute  semi-transparent  granules  supposed  to 
represent  unaltered  hepatic  tissue.  The  surface  of  the 
organ  is  either  perfectly  smooth  or  dotted  with  puncti- 
form  depressions,  probable  sites  of  localized  hepatitis 
induced  by  the  presence  of  gummata.  A  portion  only 
or  the  whole  of  the  liver  may  be  affected,  and  the 
changes  in  its  volume,  the  degree  of  its  scirrhous  hard- 
ness, and  its  shade  of  color  are  due  to  differences  in  the 
staees  of  its  involvement. 


HEREDITARY  SYPHILIS.  2\J 

The  spleen  is  enlarged  in  from  one-fifth  to  one-fourth 
of  all  cases  of  inherited  disease,  being  in  cases  many 
times  more  voluminous  than  in  health.  There  is  com- 
monly a  hyperplasia  productive  of  a  densely  indurated 
mass,  or  circumscribed  or  diffuse  gummata,  these 
changes  often  coexisting  with,  if  not  actually  produced 
by,  hepatic  lesions  of  the  disease.  A  membranous  cap- 
sulitus  occurs  in  some  cases.  The  issue  in  all  is  either 
by  complete  resolution,  which  may  result  under  proper 
treatment,  or  by  lardaceous   degeneration. 

The  rectum  and  the  amis  of  infants  affected  with  hered- 
itary syphilis  are  involved  as  in  acquired  disease,  stric- 
ture of  the  rectum,  however,  rarely  resulting.  In  infants 
not  properly  cleansed  the  production  of  condylomata, 
moist  papules,  and  secreting  tubercles  about  the  anus 
and  the  vulva  is  greatly  favored  by  the  accumulation  of 
faeces  and  urine  on  the  napkins  of  the  child. 

The  kidneys,  when  involved  in  syphilis  of  the  second 
generation,  may  present  evidences  of  interstitial  inflam- 
mation, lardaceous  degeneration,  and  alterations  in  the 
epithelium  of  the  convoluted  tubes  not  characteristic  of 
this  special  malady.  The  parenchyma  may  be  found 
studded  with  miliary  to  lenticular  sized  whitish  and  yellow 
nodules,  due  to  infarctions  of  the  renal  tissue,  with  diffuse 
or  circumscribed  infiltrations  made  up  of  round  cells.  The 
primary  enlargement  of  the  organ  may  be  followed  by 
atrophic  changes,  due  to  degeneration  of  the  cells  consti- 
tuting the  new  growth. 

The  Adrenals. — The  suprarenal  glands  may  be  affected 
in  hereditary  syphilis  with  changes  usually  conspicuous 
by  reason  of  the  enlargement  of  the  organ.  There  is 
usually,  first,  proliferation  of  young  connective-tissue 
elements,  chiefly  in  the  cortical  substance,  followed  by 
lardaceous  degeneration  and  shrinkage  in  the  size  of  the 
gland.  Care  must  be  observed  in  these  instances  not  to 
confound  the  changes  with  those  of  tuberculosis,  which 
may  occur  in  the  subject  of  the  disease. 

The  nervous  system  in  hereditary  syphilis  may  suffer 


21 8      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

from  changes  in  the  brain,  the  cord,  or  the  peripheral 
nerves,  in  their  membranous  or  osseous  envelopes,  and 
in  the  tissues  with  which  the  latter  are  in  intimate 
relation. 

The  cranial  bones  are  in  cases  characteristically  changed 
by  circumscribed  or  diffuse  atrophic  osteitis  of  gelatini- 
form  type  (the  bones  becoming  softened  to  the  con- 
sistency of  jelly,  or  presenting  a  "  worm-eaten  "  appear- 
ance), or  by  osteophytic  osteitis,  as  a  consequence  of 
which  bosses  (nodes,  exostoses,  hyperostoses)  form  in 
special  regions,  producing  in  the  skull  of  the  infant  a 
highly  characteristic  deformity.  In  one  type  the  cranial 
bones  are  merely  symmetrically  changed  and  fixed  or 
floating;  in  another  they  bulge  as  in  hydrocephalus; 
in  another  the  forehead  pushes  forward  above,  producing 
the  effect  of  massiveness  ;  in  another  each  frontal  pro- 
tuberance is  symmetrically  studded  with  circumscribed 
rounded  bosses  or  prominences  ;  in  yet  another  the  brow 
edges  forward  in  the  mesian  line,  producing  a  keel-like 
aspect.  Microcephalus  may  result  either  from  formative 
osteitis  making  a  cruciform  or  other  shaped  bridge  over 
the  fontanelles,  thus  interfering  with  the  development  of 
the  skull,  or  from  simple  failure  of  evolution,  the  stunting 
being  dependent  upon  general  rather  than  upon  local 
causes.  Whether  or  not  this  condition  and  that  of 
rachitis  be  due  in  some  cases  to  syphilis  indirect^,  and 
in  others  to  different  morbid  states  not  well  understood, 
is  not  fully  determined.  The  general  belief  among 
experts  is  that  these  and  other  evidences  of  failure  of 
development  are  symptoms  of  cachectic  states  which 
may  be  induced  by  syphilis  and  other  affections. 

Subacute  and  chronic  types  of  leptomeningitis,  in 
which  the  dura  mater  or  the  pia  mater  may  be  involved 
primarily  or  secondarily  in  gummatous  change ;  are  not 
rare  among  syphilitic  children  ;  they  require  to  be  com- 
pared closely  with  the  other  signs  of  inherited  lues,  in 
order  to  be  differentiated  from  tubercular  affections  of  the 
meninges.    Hemorrhages  are  occasional  complications  of 


HEREDITARY  SYPHILIS.  2ig 

these  attacks,  provoked  by  the  presence  of  gummata  in 
the  cranial  bones  or  in  the  pericranium.  The  cerebrum, 
the  cerebellum,  the  pons,  and  the  medulla  may  each  be 
the  seat  of  changes  produced  by  any  of  the  forms  of 
arteritis  studied  in  connection  with  the  brain-syphilis  of 
acquired  disease,  the  ultimate  results  being  seen  in  the 
formation  of  aneurysmal  pouches,  irregular  distribution 
of  blood  to  the  nervous  tissue,  thrombosis,  embolism, 
and  hemorrhages.  Gummata,  as  in  acquired  disease, 
may  develop  in  the  nervous  substance ;  and  endarteritis, 
encephalitis,  cerebral  sclerosis,  ependymitis,  ecchymosis, 
and  softening  may  ultimately  result. 

The  clinical  symptoms  springing  from  these  organic 
changes,  slight  or  severe,  vary  from  feeble-mindedness 
and  mental  states  suggestive  of  complete  idiocy  to  chorea, 
mild  or  severe,  insanity  and  epileptiform  attacks,  though 
the  latter  are  rarer  in  congenital  than  in  acquired  disease. 
Single  or  multiple  paralyses  of  centric  origin,  hemiplegias 
and  paraplegias,  with  the  usual  accompaniment  of  severe, 
continued,  or  recurrent  headache,  are  common  results 
of  these  intracranial  lesions.  Recurrence  of  nervous 
.  phenomena  of  a  severe  grade,  a  distorted  cranium,  and 
an  idiotic  mental  state  point  to  inherited  syphilis  of  the 
child  even  in  the  absence  of  any  history  of  infection  of 
one  or  both  parents.  The  evidences  of  inherited  disease, 
in  the  rare  instances  in  which  the  cord  and  the  periph- 
eral nerves  are  involved,  are  obscure.  Cases  are  rare  in 
which  opportunity  is  offered  for  their  investigation.  The 
oculo-motor  paralyses  of  acquired  disease  are  here  oc- 
casionally noted.  As  coincident  symptoms,  it  is  impor- 
tant in  forming  a  diagnosis  to  establish  the  fact  of  a  kera- 
titis, a  chorioiditis,  a  retinitis,  or  an  optic  neuritis. 

The  eye  in  inherited  syphilis  is  subject  to  many  of  the 
disorders  observed  in  acquired  disease.  Parenchyma- 
tous keratitis  (chronic  interstitial  keratitis)  is  often  found 
associated  with  the  teeth  described  by  Hutchinson, 
already  noted,  the  combination  of  the  two  affections 
practically  establishing  a  diagnosis  of  inherited  syphilis. 


220      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

The  cornea  in  these  cases  first  becomes  cloudy  in  punc- 
tate lesions  recognized  on  close  inspection  as  seated  in 
the  parenchymatous  tissue.  Gradually,  in  the  course  of 
a  few  weeks  or  less,  the  entire  cornea  presents  a  cha- 
racteristic "  ground-glass  "  appearance,  in  consequence 
of  the  multiplication  and  fusion  of  these  points  of  opacity, 
with  a  pericorneal  zone  of  injection,  one  or  both  eyes 
being  attacked,  and  the  two  organs  simultaneously  or 
successively.  The  issue  is  either  a  gradual  clearing  up 
of  the  opaque  condition,  which  at  its  fullest  evolution 
practically  occludes  the  entrance  of  light,  or  a  more  or 
less  intense  injection  and  vascularization  of  the  corneal 
surface.  Iritis  is  rarer  in  inherited  than  in  acquired 
disease,  but  it  occurs  in  one  or  both  eyes  and  before  or 
after  birth,  plastic  effusions  in  the  worst  cases  gluing 
the  iris  to  the  capsule  of  the  lens.  Choroiditis  and 
retinitis  also  occur  in  inherited  disease,  with  the  iris 
and  the  pupil  unchanged,  and  dust-like  particles  in  the 
vitreous  humor  originating  in  patches  of  infiltration  of 
the  choroid.  Retinitis  and  optic  neuritis  in  children 
have  rarely  been  observed. 

The  Ear. — The  persistent  deafness  of  many  subjects  of 
inherited  syphilis  arise  from  changes  in  the  tympanum 
and  the  middle  ear.  The  lesions  correspond,  for  the  most 
part,  with  those  heretofore  described  in  connection  with 
acquired  syphilis.  The  deafness  is  due,  in  general,  to  a 
labyrinthitis  characterized  by  a  cellular  infiltration  of  the 
membranous  labyrinth  and  to  a  serous  effusion  into  the 
endolymph,  with  eventual  increase  of  connective  tissue 
which  may  later  undergo  a  species  of  cicatricial  con- 
tracture. Prominent  subjective  symptoms  are  the  usual 
morbid  aberrations  of  audition  (roaring,  blowing,  ring- 
ing, singing,  and  other  sensations),  more  or  less  rapidly 
changing  to  absolute  surdity.  There  may  be,  as  in  adults, 
coincident  vertigo,  cephalalgia,  naso-pharyngeal  catarrh, 
and  occasionally  disturbances  of  the  equilibrium,  with 
febrile  phenomena. 

Hemorrhagic  syphilis  of  the  second  generation  is  not 


TREATMENT  OF  SYPHILIS.  221 

of  very  rare  occurrence.  The  lesions  may  be  cutaneous 
petechias,  ecchymoses,  and  ecchymomata  of  either  the 
skin  or  the  mucous  membranes ;  or  the  viscera  may  be 
involved.  Haemorrhage  from  the  umbilical  vein  is  an 
early  and  often  fatal  sign  of  the  systemic  dyscrasia,  which 
may  lead  to  a  fatal  termination.  These  cases  are  to  be 
distinguished  from  haemophilia. 


TREATMENT  OF  SYPHILIS. 

No  treatment  of  syphilis  may  be  regarded  as  worth 
the  name  that  excludes  early  and  persistent  attention 
to  the  general  health  of  the  patient.  This  hygienic  care, 
as  contrasted  with  the  medicinal  measures  employed,  by 
far  outweighs  the  latter  in  importance,  and  practically 
decides  for  many  cases  the  question  of  the  gravity  of 
the  issue  or  the  reverse.  The  worst  errors  committed 
in  the  management  of  syphilis  are  due  to  trusting 
exclusively  in  the  efficacy  of  drugs  for  relief  of  the 
disease. 

Hygienic  Considerations. — The  patient  affected  with 
syphilis  should  always  be  given  a  sufficiently  ample 
dietary,  the  food  to  be  simple  and  digestible.  For  the 
gouty  the  food  should  not  be  that  allowed  the  cachectic 
and  the  anaemic.  Allowance  being  made  for  these  ex- 
tremes, it  may  be  said  in  general  that  the  syphilitic 
patient  requires  an  ample  supply  of  nutritious  and 
digestible  food,  seeing  that,  even  in  the  case  of  the  sub- 
ject of  the  disease  who  is  at  the  outset  well  fed  and  well 
nourished,  it  cannot  always  be  known  when  the  toxines 
of  his  malady  may  so  change  the  systemic  condition  that 
at  a  date  not  far  distant  the  picture  may  be  altered  for 
the  worse. 

Alcoholic  beverages  may  be  used  in  the  treatment  of 
syphilis  with  wise  discretion.  In  the  case  of  the  enfee- 
bled the  weaker  stimulants,  such  as  white  wines,  beer, 


222      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

ale,  porter,  and  the  malt  extracts,  may  often  be  employed 
with  great  advantage  to  the  patient;  while  the  use  of 
such  articles  as  spirits,  champagne,  and  Burgundy  or 
Port,  if  drunk  freely  and  in  persons  of  a  gouty  state, 
may  be  positively  injurious,  and  may  actually  prolong 
the  period  during  which  the  malady  requires  treatment. 
Here,  as  in  so  many  questions  arising  in  medicine,  the 
judgment  of  the  practitioner,  instead  of  a  fixed  rule, 
must  finally  decide. 

Bathing  is  of  importance  in  all  cases.  The  very  hot 
baths  largely  employed  in  the  various  health-resorts 
and  springs  of  all  countries  are  without  question  often 
harmful,  and  are  to  be  ordered  for  the  average  patient 
only  after  due  consideration.  The  skin  of  the  body, 
however,  should,  when  practicable,  be  sponged  daily, 
exception  being  made  for  the  menstrual  period  in  women. 
Persons  of  a  delicate  constitution  should  simply  moisten 
a  handful  of  warmed  salt  with  hot  water  and  rub  this 
over  the  skin-surface,  using  afterward  a  coarse  towel  or  a 
flesh-brush  to  ensure  a  vivid  reaction.  For  stronger 
patients,  especially  vigorous  young  men,  daily  cold 
sponging  of  the  entire  body,  from  the  neck  to  the  feet, 
with  water  to  which  salt  has  been  added  in  the  strength 
of  one-quarter  of  a  pound  to  the  gallon  is  of  high  value. 
Hot  baths  and  hot  applications  of  all  sorts  for  a  skin 
liable  to  exhibit  a  syphilitic  exanthem  are  decidedly 
objectionable.  By  keeping  the  surface  well  polished  and 
in  a  high  degree  of  tone  the  liability  to  pustular  and 
other   syphilodermata  is  practically  set  aside. 

The  use  of  tobacco,  either  by  smoking,  by  chewing,  or 
as  snuff,  is  harmful  to  the  mouth  and  to  the  nares  of 
syphilitic  subjects,  inviting  as  it  does  the  occurrence  in 
these  parts  of  mucous  patches  and  other  lesions.  It  is 
decidedly  the  wisest  course  in  every  case  to  interdict 
absolutely  these  practices  from  first  to  last.  In  the  same 
connection  it  is  well  to  remember  that  male  patients 
deprived  of  tobacco  are  apt  to  hold  cigars  or  a  tooth- 
pick in  the  mouth,  or  even  to  chew  gum  for  hours  at  a 


TREATMENT  OF  SYPHILIS.  223 

time,  in  order  to  allay  the  craving  for  tobacco.  Each 
of  these  practices  is  harmful,  and  has  repeatedly  pro- 
duced the  most  painful  and  persistent  fissures  of  the 
commissures  of  the  lips,  and  even  obstinate  ulcers. 

It  is  well  to  bear  in  mind  the  measures  recognized  as 
efficient  in  the  management  of  other  disorders  producing 
deterioration  of  the  general  health.  Diversion  of  the 
mind,  abstraction  from  the  fatigue  and  anxiety  of  busi- 
ness and  professional  work,  foreign  and  domestic  travel, 
the  invigorating  influences  of  a  sea-voyage  or  a  sojourn 
in  the  mountains,  out-door  living  and  open-air  amuse- 
ments,— all  these  have  a  distinct  value  in  appropriate 
cases. 

The  recently  infected  subjects  of  syphilis,  and  often 
those  who  have  suffered  longer,  should  in  general  ex- 
clude the  possibility  of  a  determination  of  the  activities 
of  the  disease  to  any  one  region  of  the  body  by  setting 
aside,  so  far  as  practicable,  all  local  sources  of  irritation. 
Carious  teeth  should  be  removed  or  their  cavities  be 
stopped ;  projecting  edges  of  teeth  in  contact  with  the 
tongue  should  be  removed  by  the  dentist's  file ;  a  weak 
eye  (particularly  if  employed  out  of  doors  with  snow 
on  the  ground)  should  be  protected ;  and  a  ponderous 
varicocele,  a  scrotal  hernia,  or  a  hemorrhoidal  tumor 
should  receive  proper  attention. 

Time  for  beginning-  the  Systemic  Treatment  of 
Syphilis. — It  has  already  been  shown  that  treatment  of 
the  chancre,  whether  by  internal  or  external  medication, 
is  not  the  treatment  of  the  disease  which  follows.  At- 
tempts to  abort  syphilis  at  the  onset  are  usually  as 
futile  as  similar  efforts  to  jugulate  the  other  maladies 
with  which  man  may  be  affected.  In  any  case  in  which, 
whether  from  the  local  phenomena  (initial  sclerosis, 
syphilitic  bubo)  or  from  special  conditions  aside  from  the 
local  symptoms,  it  is  deemed  prudent  to  begin  the  treat- 
ment of  syphilis  before  the  establishment  of  an  absolute 
certainty  respecting  its  diagnosis,  general  treatment  may 
properly  be  instituted,  with  the   distinct  understanding 


224      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

that  such  treatment  will  neither  assuredly  abort  nor  miti- 
gate the  symptoms  which  are  to  be  expected  later. 
The  reverse  is  also  true — namely,  that  delay  in  insti- 
tuting systemic  treatment  of  syphilis  until  the  fullest 
recognition  of  the  disease  has  been  established  in  no 
wise  jeopards  the  future  of  the  patient  nor  his  amena- 
bility to  the  later  management  of  his  malady.  It  has 
already  been  set  forth  in  these  pages  that  in  a  sound 
young  patient  free  from  signs  of  other  trouble,  infected 
with  syphilis  and  properly  treated  thereafter,  there  would 
probably  result  but  a  single  exanthem  (the  macular 
syphiloderm),  upon  the  disappearance  of  which,  when 
all  the  other  hygienic  and  therapeutic  conditions  were 
absolutely  fulfilled,  no  other  symptom  of  the  disease 
should  follow.  However  impossible  the  attainment  of 
such  an  ideal,  its  practical  realization  in  selected  cases 
points  with  clearness  to  the  clinical  fact  that  some  ex- 
pression of  the  disease,  early  or  late,  is  in  the  nature  of 
the  affection  to  be  expected.  After  such  complete  ex- 
pression subsequent  processes  may  be  in  the  line  of  in- 
volution rather  than  of  evolution.  A  very  abundant 
macular  syphiloderm  not  uncommonly  disposes  of  the 
major  part  of  all  symptoms  of  systemic  syphilis,  and  if 
this  first  exanthem  be  aborted,  suppressed,  or  greatly  in- 
fluenced by  energetic  treatment  (which  is  certainly  in 
some  cases  effected),  the  future  of  the  patient  is  to  a 
degree  clouded.  One  early  vivid  and  generalized  efflo- 
rescence is  an  augury  for  good  in  an  otherwise  healthy 
subject.  No  treatment  is  superior  in  results  to  that 
directed  with  energy,  system,  and  skill  to  a  disease  per- 
mitted a  first  frank  evolution. 

The  question,  often  formulated,  "  How  long  should 
the  treatment  of  syphilis  be  continued  ?"  is  best  answered 
by  stating  the  length  of  time  during  which  the  disease 
may  persist.  For  some  patients  the  disease  and  the 
treatment,  as  has  already  been  seen,  are  alike  ended  long 
before  other  infected  subjects  have  ceased  to  exhibit 
symptoms  or  to  be  treated  for  their  relief.     The  treat- 


TREATMENT  OF  SYPHILIS.  225 

ment  of  rebellious  syphilis  in  the  unfavorable  class  of 
patients  already  described  is,  indeed,  a  tedious  matter. 
For  the  average  of  subjects  of  the  disease,  healthy  before 
infection  and  managed  skilfully,  it  is  not  difficult  to  fix 
the  duration  of  treatment.  Most  of  such  patients  after 
two  and  one-half  or  three  years  have  passed  are  prac- 
tically well.  There  are  few  sound  persons  thus  cared 
for  who  may  not  suspend  medication  for  weeks  at  a  time 
after  the  conclusion  of  the  second  year. 

Systemic  Treatment  of  Syphilis. — Medicinal  treat- 
ment of  syphilis  is  conducted  by  the  aid  of  remedies 
both  ingested  and  externally  applied.  The  former 
method  is  usually  termed  "  internal,"  as  distinguished 
from  "  external  "  treatment.  Both  methods  have  been 
employed  at  different  periods  of  time,  either  sepa- 
rately or  in  conjunction,  with  favorable  results.  These 
modes  of  medicinal  treatment  have  been  by  some 
writers  made  to  conform  to  certain  systems ;  as,  for 
example,  the  so-called  "  tonic "  method,  in  accord- 
ance with  which  a  dose  ascertained  to  be  effective 
in  the  case  of  a  single  individual  is  continuously  ad- 
ministered for  a  given  length  of  time — a  number  of 
consecutive  months  or  years.  Another  system  is  the 
"  interrupted,"  in  accordance  with  which  the  patient  is 
submitted  to  treatment  of  the  disease  by  special  medica- 
ments for  a  period  of  time,  followed  by  a  longer  or 
shorter  suspension  of  the  remedy.  Of  the  so-called 
"  expectant "  method  of  treating  syphilis  it  is  sufficient  to 
say  that  few  modern  practitioners  would  dare  to  subject 
themselves  to  the  charge  of  leaving  a  patient  affected 
with  the  disease  to  such  grave  possibilities  of  danger- 
ous and  even  fatal  results.  In  these  pages  the  effort  is 
made  to  set  forth  the  treatment  of  syphilis  on  a  rational 
basis,  and  wholly  independent  of  any  system  whatever. 
Indeed,  the  skilful  physician  will  ever  free  himself  from 
the  shackles  of  conventional  rules,  and  will  learn  by 
experience  to  employ  with  advantage  for  his  patients  the 
method  which  in  each  single  case  is  most  clearly  indi- 

15 


226      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

cated  and  best  adapted  not  merely  to  relieve  for  the 
time  being  the  symptoms  of  the  disease,  but  also  to  set 
aside  its  possibilities  of  damage  in  the  remote  future. 

Mercury. — In  the  face  of  vast  opposition,  and  despite 
the  fact  that  a  large  number  of  the  lesions  of  syphilis 
have  been  attributed  where  they  do  not  belong — to  the 
assumed  toxic  effect  of  the  metal  which  is  of  chief  value 
in  securing  its  relief — mercury  to-day  stands  pre-eminent 
throughout  the  civilized  world  among  drugs  esteemed 
efficient  both  for  the  relief  of  the  symptoms  and  for  the 
radical  cure  of  the  disease.  Like  most  agents  that  are 
both  energetic  and  efficient,  it  is  not  a  proper  use,  but 
an  abuse,  of  its  compounds  that  has  brought  upon  it  so 
much  odium. 

It  has  long  been  regarded  as  axiomatic  that  mercury 
is  chiefly  valuable  in  the  early,  and  the  preparations  of 
iodine  in  the  later,  periods  of  syphilis.  In  general  this 
may  be  admitted  to  be  true ;  but  the  exceptions  to  the 
rule  are  so  many  that  it  may  often  be  violated  with  the 
greatest  possible  advantage  to  the  patient. 

The  preparations  of  mercury  administered  by  the 
mouth  are,  in  the  order  of  their  value  in  the  manage- 
ment of  syphilis,  the  protoiodide,  the  bichloride,  the 
biniodide,  the  tannate,  blue  pill,  calomel,  and  the  gray 
powder.  Among  American  and  French  physicians  the 
protoiodide  has,  and  we  think  justly,  a  decided  prefer- 
ence. 

On  the  supervention  of  the  first  symptoms  of  general 
syphilis,  it  is  well,  when  the  method  of  treatment  by  the 
mouth  with  digestion  of  drugs  in  the  stomach  is  selected, 
to  begin  with  a  mercurial  course  by  the  aid  of  the  pro- 
toiodide. This  preparation  is  to  be  exhibited  steadily 
until  all  obvious  symptoms  of  the  disease  are  removed, 
and  afterward  to  an  extent  hereafter  to  be  discussed.  It 
is  well  to  begin  with  an  average  dose  of  the  metallic  salt, 
and  to  increase  or  decrease  this  dose  as  indications  may 
be  furnished  by  the  patient.  Whether  one  or  another 
article  be  selected  for  use,  that  medication  only  can  be 


TREATMENT  OF  SYPHILIS.  22J 

regarded  as  both  efficient  and  desirable  which  is  not 
intolerable  to  the  system,  under  the  influence  of  which 
the  patient  gains  in  weight,  and  which  enables  him  to 
digest  food  with  appetite  and  profit  as  regards  nutrition. 
The  following  are  practicable  formulae  for  the  pur- 
poses named : 

i^.  Hydrarg.  iodid.  virid.,  gr.  xij  ; 

Mas.  ferri  carb.,  3j. — M. 

Ft.  pil.  No.  lx. 

Sig.  One  or  two  pills  after  each  meal. 

From  j!q  to  \  grain  may  thus  be  given  after  each  meal 
to  a  patient  of  adult  years  and  average  weight.  The 
dose  may  be  reduced  or  increased  from  day  to  day  as 
required — diminished  especially  if  there  be  looseness  of 
the  bowels,  which  to  an  extent  is  guarded  against  by 
the  use  of  the  ferruginous  preparation  named.  For 
Vallet's  mass  the  citrate  of  iron  and  quinine  may  be  sub- 
stituted in  doses  of  from  I  to  3  grains. 

When  looseness  of  the  bowels  or  colic  is  induced,  the 
dose  should  be  diminished  or  the  habits  of  the  patient 
with  respect  to  food  and  drink  should  be  controlled  more 
carefully.  The  drinking  of  iced  water,  the  eating  of  ice- 
cream, and  the  free  use  of  fruits  and  of  certain  kinds  of 
fish  are  often  responsible  for  the  excessive  action  of  the 
bowels  and  for  the  pain  induced  by  the  drug. 

Instead  of  in  pills,  the  combination  given  may  be 
administered  in  capsules,  the  preparations  for  this 
purpose  lately  placed  upon  the  market  being  readily 
digested  and  more  soluble  even  in  the  fluids  of  the 
mouth  than  a  coated  pill  which  has  been  desiccated  by 
time  and  by  hot  weather.  The  tablet  triturates  of  the 
same  metal  are  often  used,  but  are  open  to  the  disadvan- 
tage of  disintegrating  when  carried  about  in  the  pocket. 
The  centigram  granules  of  Messrs.  Gamier  &  Lamoureux, 
which  have  long  been  esteemed  highly  in  America 
and  abroad  in  the  management  of  the  disease,  are  cer- 
tainly of  great  value,  as  the  pill  is  elegantly  made  and 


228      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

is  efficiently  preservative  of  its  contents.  Upon  com- 
parison with  pills  of  the  same  dose  of  American  manu- 
facture, made,  for  the  most  part,  by  skilful  precipitation 
of  the  green  iodide,  the  latter  will  in  general  be  found 
to  be  superior.  The  French  pill,  however,  has  an  actual 
advantage  in  the  greater  impurity  of  its  constituents. 
For  therapeutic  purposes  the  dose  of  the  yellow  pro- 
toiodide  in  pill  form,  made  by  American  chemists,  should 
be  nearly  one-half  that  prepared  by  the  French  in  the 
pill  named. 

It  is- very  rarely  necessary  to  give  an  opiate  in  com- 
bination with  mercurials  in  the  treatment  of  syphilis, 
with  a  view  to  the  introduction  of  a  larger  quantity  of 
the  metal  into  the  system,  or  to  relieve  the  diarrhoea 
produced  by  even  small  doses.  This  practice  is  a  rem- 
nant of  crude  attempts  at  treatment  instituted  before  the 
days  of  modern  refinement  in  diagnosis  and  methods. 
It  is  to  be  regarded  as  a  last  resort  for  cases  of  extreme 
urgency  and  of  very  unusual  irritability  of  the  intestinal 
canal.  Not  merely  may  the  combination  beget  the 
opium-habit  in  a  person  thus  habituated  to  the  drug 
(and  frequently  such  habits  have  been  acquired  during 
treatment  for  syphilis),  but  harm  is  wrought  by  inter- 
ference with  digestion.  He  who  hopes  to  be  brilliantly 
successful  in  managing  syphilis  will  ever  be  jealous  of 
any  impairment  of  the  digestive  functions  of  his  patient. 

"  A  chronic  disease,"  as  a  great  syphilographer  has 
written,  "  requires  a  chronic  remedy."  Without  adher- 
ing to  any  system,  if  it  be  found  that,  by  steadily  pursu- 
ing a  mercurial  course  with  the  aid  of  the  protoiodide, 
the  symptoms  of  the  disease  disappear,  and  afterward 
the  patient  can  still  take  the  drug  to  advantage  in  doses 
that  enable  him  to  gain  in  weight  or  to  hold  it  at  nearly 
the  maximum  while  attending  to  his  or  her  usual  voca- 
tion, meantime  enjoying  every  sign  of  good  health,  a 
desirable  and  satisfactory  end  has  been  obtained.  Cer- 
tainly no  change,  under  these  circumstances,  is  specially 
desired  or  required.     It  is  well,  when  this  fortunate  issue 


TREATMENT  OF  SYPHILIS.  220, 

is  reached,  to  have  the  patient  kept  under  more  or  less 
careful  observation,  the  practitioner  being  at  all  times 
ready  to  change  the  treatment,  general  or  local,  as 
may  from  day  to  day  be  suggested  by  any  accidents 
that  arise. 

At  any  time,  however,  when  such  a  course  seems 
desired,  any  one  of  the  other  preparations  of  the  metal 
named  may  be  substituted  for  the  protoiodide.  These 
preparations  are  the  bichloride,  in  doses  of  from  -^  to 
-^2  grain  ;  the  biniodide,  in  doses  of  from  ^to  jg  grain  ; 
the  tannate,  in  doses  of  from  ^  to  I  grain ;  blue  pill,  in 
doses  of  from  |  to  1  grain ;  calomel,  in  doses  of  from 
jig-  to  I  grain ;  and  the  gray  powder,  in  doses  of  from  1 
to  5  grains.  Of  these  preparations,  the  biniodide,  the 
tannate,  blue  pill,  calomel,  and  hydrargyrum  cum  creta 
may  be  given  in  pill  form ;  the  bichloride  and  the  bin- 
iodide preferably  in  solution ;  and  calomel  and  the  gray 
powder  in  the  form  of  either  powders  or  pills.  It  is  to 
be  remembered  that  in  giving  mercury  it  is  not  so 
important  to  discover  how  large  a  dose  a  patient  may 
take  with  impunity  at  one  time  for  the  relief  of  his 
disease  as  to  know  how  large  a  dose  may  be  taken  for 
long  periods  of  time  with  the  same  end  in  view.  It  is 
rarely  necessary  to  give  more  than  3  grains  of  the  pro- 
toiodide by  the  mouth  daily,  nor  more  than  J  or  ^  grain 
of  the  sublimate,  nor  more  of  the  other  compounds 
named  than  can  be  regarded  as  an  average  rather  than 
as  a  large  dose. 

Upon  the  slightest  evidence,  however,  even  when  any 
of  these  doses  is  being  pushed  to  a  proper  maximum, 
that  the  disease  or  its  symptoms  is  not  properly  yielding, 
there  can  be  but  little  question  that  the  proper  course  is 
to  change  the  preparation  selected.  In  syphilis  the  in- 
fective cells  become  later  less  amenable  than  at  first  to 
the  antagonizing  remedy,  and  each  group  of  these  cells 
may  become  a  focus  from  which,  by  the  well-known 
processes  of  cell-multiplication  and  the  production  of 
toxines,  the  morbid  process  may  be  relighted  to  activity. 


230      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

Even  the  most  trivial  of  lesions  is  to  be  combated 
energetically  in  this  early  stage  ;  and  when  resolution 
is  not  visibly  progressing,  not  only  is  the  remedy  for 
internal  use  to  be  exchanged  for  another,  but  the  topical 
treatment  of  any  lesions  present,  as  explained  elsewhere, 
should  either  be  modified  or  be  more  energetically  and 
persistently  pushed. 

The  season  for  the  happiest  results  from  the  manage- 
ment of  syphilis  is  the  first  semester  of  its  career.  If 
any  treatment  may  justly  be  described  as  "abortive,"  it 
is  not  that  which  seeks  to  jugulate  the  malady  in  its 
chancre-stage,  but  that  which  vigorously  and  efficiently 
obliterates  all  symptoms  in  the  period  of  early  evolu- 
tion. 

We  believe  that  when  all  progresses  satisfactorily,  the 
patient  who  secures  complete  immunity  from  symptoms 
of  his  disease  in  the  first  half  year  does  better  when  no 
recognized  antisyphilitic  remedy  is  administered  save 
mercury.  Many  of  the  best  treated  patients  have  never 
swallowed  the  compounds  of  iodine  except  in  combina- 
tion with  mercury.  Other  things  being  equal,  he  who 
has  secured  complete  relief  from  syphilis  without  using 
the  iodide  of  potassium  has  usually  had  either  a  mild  or 
an  exceedingly  tractable  form  of  the  disease. 

Iron  is  administered  with  decided  advantage  to  the 
great  majority  of  all  patients  affected  with  syphilis,  and 
it  is  well  to  order  it  in  all  cases  where  it  is  not  contra- 
indicated.  A  convenient  method  is  to  prescribe  a  ferru- 
ginous tonic  before  the  first  and  the  last  meal  of  each  day, 
while  the  mercurial  in  pill  or  other  form  is  taken  after 
each  meal.  Iron  does  its  best  work  for  most  patients 
when  ingested  in  a  fluid  form.  The  following  is  a  con- 
venient formula  : 

1^.    Ferri  et  quin.  citrat.,  §ss  ; 

Limon.  syrup.,  fsij  ; 

Aq.  destill.,  ad  fgviij. — M. 

Sig.  A  teaspoonful  in  a  wineglassful  of  water  before  the 
first  and  the  last  meal  of  the  day. 


TREATMENT  OF  SYPHILIS.  23  I 

Iron  may  also  be  given  in  pill  form  or  be  combined  with 
the  bichloride  in  formulas  of  which  the  following  may 
be  taken  as  a  sample  : 

3^.    Hydrarg.  chlorid.  corros.,  gr.  j-ij ; 

Ferri  tinct.  muriat, 

Acid  muriat.  dilut,  da.  feij-iv; 

Syr.  aurant.  flor.,  C§ij ; 

Aq.  dest,  ad  fgviij.—  M. 

Sig.  A  teaspoonful  in  a  wineglassful  of  water  after  each 
meal. 
When  there  is  constipation,  patients  often  find  it  of 
advantage  to  take  some  such  formula  as  that  given 
above,  in  proper  doses  after  the  first  and  the  last  meal  of 
each  day,  and  one  or  two  pills  or  tablets  of  the  pro- 
toiodide  after  the  middle  meal  of  the  day. 

Inunction  of  mercury,  or  its  systematic  introduction 
by  the  skin,  is  one  of  the  superior  methods  of  treating 
syphilis.  This  practice  has  the  excellent  recommendation 
of  sparing  the  stomach,  which  may  then  be  reserved  for 
food  and  drink,  for  tonics,  and  for  whatever  else  in  the 
way  of  adjuvant  ingesta  may  at  any  time  be  required.  The 
disadvantages  of  inunction  are  its  relative  uncleanliness 
and  the  need  of  more  or  less  skill  and  time  in  its  em- 
ployment. Few  patients  of  the  better  class  like  to  resort 
to  it  for  more  than  brief  periods  of  time.  There  are  few, 
however,  who  may  not  reap  substantial  benefits  from 
smearing  mercury  even  for  short  periods.  It  is  wise  to 
employ  inunction,  first,  in  all  grave  cases ;  second,  in  all 
cases  of  emergency ;  third,  whenever  the  stomach  proves 
intractable  to  drug-ingestion  ;  and  fourth,  whenever,  even 
after  generally  favorable  results  from  medication  by  the 
mouth,  there  are  persistent  lesions  refusing  to  yield  to 
general  and  local  treatment. 

Mercurial  ointment  of  the  United  States  Pharma- 
copoeia, in  50  per  cent,  strength,  still  heads  the  list  of 
mercurial  preparations  available  for  inunctions.  It  can- 
not be  employed  with  equal  advantage  in   combination 


232      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

with  any  drug.  Mercurial  plasters  have  in  some  cases 
a  decidedly  beneficial  result  as  local  applications ;  and 
the  5,  10,  and  20  per  cent,  oleates  may  also  at  times  be 
used  with  advantage  when  there  is  no  special  urgency. 
No  such  reliance,  however,  can  be  placed  upon  them  as 
upon  the  officinal  blue  ointment. 

When  inunction  is  to  be  employed,  the  dose  of  the 
ointment  should  be  varied  according  to  the  weight  and 
the  general  condition  of  the  patient,  from  1  to  3  scruples 
being  ordered  to  be  well  rubbed  in  at  a  single  sitting. 
The  smaller  may  often  with  advantage  in  any  given  case 
be  increased  to  the  larger  dose  named.  The  skin 
should  usually  have  a  preliminary  cleansing  in  tepid 
water  with  soap,  and  often  also  a  washing  with  borated 
water  or  with  alcohol  in  order  to  ensure  an  aseptic  state 
of  the  skin.  Professional  rubbers  generally  do  better 
service  than  untrained  servants  or  the  subjects  of  the 
disease  themselves  ;  but  often  the  last  named' — especially 
women  who  are  anxious  not  to  betray  to  others  the 
nature  of  their  malady — learn  to  practise  inunction  with 
excellent  results.  The  ointment  should  be  rubbed  in 
until  it  has  practically  disappeared,  with  a  gentle  knead- 
ing motion  of  the  hand,  or,  better,  the  two  hands — 
practically  the  movement  used  in  massage.  The  hand 
of  an  assistant,  if  such  be  employed,  need  not  be  pro- 
tected by  gloves,  seeing  that  a  talc  paste  such  as  the 
modified  Lassar  may  practically  be  made  protective. 
The  rubbings  are  preferably  made  at  night,  after  which 
the  patient  retires  to  bed  in  clothing  which  is  suffered 
to  be  soiled  by  contact  with  the  salve.  Diaphoresis 
induced  by  the  drinking  of  hot  fluids  afterward  (milk, 
spirits,  etc.),  recommended  by  some  authors,  is  unneces- 
sary in  order  to  secure  the  best  results  of  the  treatment. 
In  hospitals  it  is  customary  to  make  the  patients  rub 
each  other,  usually  on  the  back  and  simultaneously,  the 
ward  nurse  having  then  to  anoint  but  a  single  patient  in 
the  line.  It  is  usual  to  order  from  one  to  four  or  five 
scores  of  rubbings,  to  be   given  on  successive  or  alter- 


TREATMENT  OF  SYPHILIS.  233 

nate  nights  or  at  intervals  of  several  days.  Often  it  is 
desirable  to  give  a  course  of  twenty  inunctions,  after 
which  the  rubbing  may  be  suspended  while  other  treat- 
ment is  pursued,  the  inunctions  being  renewed  until  the 
entire  number  advised  is  completed.  When  required, 
for  special  reasons,  a  useful  method  of  inunction  is  to 
order  the  skin  well  rubbed  with  the  salve,  the  part 
anointed  being  then  covered  by  the  customary  clothing, 
which  is  worn  afterward  for  a  series  of  days.  In  this 
way  stockings  impregnated  with  the  ointment  may  be 
kept  in  contact  with  the  feet,  while  flannel  undergar- 
ments may  be  employed  with  the  same  end  in  view. 
There  are,  however,  few  patients  who  relish  the  dirtiness 
and  messiness  of  this  practice,  which  is,  in  general,  to 
be  reserved  for  special  cases,  such  as  those  where 
neither  the  patient  nor  professional  masseurs  can  do  the 
work. 

When  giving  inunctions,  the  rule  enunciated  with 
respect  to  mercury  by  the  mouth  should  not  be  forgot- 
ten. The  ferruginous  tonics  are  to  be  administered 
systematically  while  the  patient  is  under  the  influence 
of  the  metal.  He  should  also  be  given  a  generous  diet 
and  should  have  out-door  air  and  exercise. 

The  regions  selected  for  inunction  of  the  body  are  of 
some  importance,  as  it  is  desirable  that  the  ointment  be 
rubbed  into  those  parts  where  the  skin  is  provided  with 
glands  through  whose  excretory  orifices  the  metal  may 
gain  access  to  the  economy.  It  is  also  desirable,  in  view 
of  the  readiness  with  which  mercurial  inunctions  induce 
an  artificial  dermatitis  in  the  region  of  application,  that 
a  new  area  of  inunction  be  selected  on  successive  days. 
This  area  secured,  however,  the  refinements  of  authors 
respecting  the  selection  of  special  regions  of  the  body 
for  inunction  have  little  foundation  in  the  way  of  attain- 
ing practical  results.  Inunctions  of  the  thick  sole  of  the 
foot  are  often  as  efficient  as  those  on  the  sensitive  and 
thinner  integument  of  the  groin  or  over  the  subclavian 
regions. 


234      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

We  are  in  the  habit  of  ordering  inunctions  first  for 
regions  of  the  upper  segment  of  the  body  in  succession, 
and  later  for  those  of  the  lower  half  successively,  for 
reasons  connected  chiefly  with  the  garment  worn  after 
the  completion  of  the  process.  In  this  way,  on  one 
night  the  thighs  and  groins,  on  another  the  legs  and 
soles,  are  anointed,  and  after  this  the  drawers  or  pajamas 
worn  are  washed ;  on  other  nights  the  surface  of  the 
belly  and  the  breast,  the  arms  and  the  axillae,  the  back, 
or  the  neck  and  the  head  may  be  smeared.  It  is  to  be 
borne  in  mind,  further,  that  when  the  inunction  is  not 
employed  with  a  view  to  acting  directly  upon  lesions 
present  upon  the  integument,  the  value  of  the  inunction 
as  regards  the  general  system  is  as  great  when  applied 
in  one  region  as  another ;  and  it  is  a  matter  of  import- 
ance to  encourage  patients,  especially  those  in  private 
practice,  to  continue  with  their  inunctions  for  the  longest 
period  advised.  For  the  most  part,  they  will  consent  to 
rubbings  of  the  lower  portions  of  the  body  for  a  longer 
time  than  to  inunctions  of  the  upper  regions.  The 
penis,  scrotum,  anus,  face,  ears,  and  the  vulva  and 
breasts  of  women  are  in  general  to  be  spared. 

There  are  few  patients,  whether  informed  or  not,  who 
remain  ignorant  of  the  nature  of  the  treatment  when 
inunctions  are  employed.  As  a  consequence,  they  are 
at  times  exceedingly  anxious  about  "  catching  cold," 
using  acids  in  their  dietary,  etc.,  for  fear  of  toxic  results. 
While  due  prudence  must  guide  the  practitioner  in 
advising  patients  on  these  points,  it  is  rare,  with  a  prop- 
erly advised  course  of  inunctions  and  with  the  subject 
of  the  disease  kept  under  the  observation  of  an  intelli- 
gent physician  (as  should  always  be  done  throughout  the 
treatment  of  syphilis),  that  accidents  happen,  even  after 
imprudent  behavior  on  the  part  of  the  patient. 

When  inunction  is  practised  with  a  view  to  direct 
medication  of  the  skin  (for  example,  in  case  of  palmar 
or  plantar  syphilodermata),  care  should  be  observed  to 
make  the   applications  so  far  as  practicable  over  all  per- 


TREATMENT  OF  SYPHILIS.  2$$ 

sistent  lesions  present.  It  is  the  skilful  obliteration  of 
all  foci  where  infective  cells,  micro-organisms,  or  toxines 
may  be  present  that  preserves  against  the  lighting  up  of 
morbid  processes  in  these  centres  of  undiminished 
activity. 

When  a  dermatitis  is  induced  by  the  frictions  inci- 
dental to  the  inunction  process  or  as  a  consequence 
of  the  mercurial  application,  the  results  are  rarely 
serious.  Discontinuance  of  further  rubbings  over  the 
region  which  thus  expresses  its  resentment  will  usually 
suffice,  in  the  course  of  a  few  days,  to  relieve  the  symp- 
toms. In  any  case  where  treatment  really  seems  needed, 
the  application  of  a  simple  dusting-powder  or  of  Lassar 
paste  usually  suffices  to  allay  the  itching  and  the  local 
irritation. 

The  modified  Lassar  paste  is  made  by  adding  2  to  4 
drachms  each  of  talc  and  zinc  oxide  to  }4  ounce  of 
white  vaseline,  with  from  5  to  20  grains  of  salicylic 
acid,  the  whole  rubbed  together  until  a  smooth  and 
impalpable  paste  results.  It  is  more  or  less  adherent  to 
the  skin,  and,  apart  from  the  value  of  its  medicinal  con- 
stituents, has  the  advantage  of  protecting  the  surface  to 
which  it  is  applied. 

Fumigation. — The  treatment  of  syphilis  by  the  aid  of 
the  mercurial  vapor-bath  is  both  efficient  and  speedy. 
In  any  emergency  it  is  capable  of  producing  more  rapid 
effects  in  a  given  time  than  any  of  the  methods  thus  far 
described.  In  the  large  cities  it  is  customary  to  send 
patients  to  bath  establishments,  where,  by  the  aid  of 
somewhat  elaborate  apparatus,  aided  by  steam-supply 
and  by  special  devices  for  exposure  of  the  head  without 
necessitating  inhalation  of  the  vapor,  the  patient  is  fumi- 
gated by  the  aid  of  trained  assistants.  However,  with 
the  Lee  or  the  Maury  apparatus,  and  an  extemporized 
chamber,  constructed  either  of  bed-blankets  or  of  ticking, 
which  can  be  fashioned  by  any  seamstress  so  as  to  en- 
compass the  patient's  body  as  high  as  the  neck,  the  same 
results  can  be  attained  with  trifling  trouble  and  expense. 


236      SYPHILIS  AND    THE    VENEREAL   DISEASES. 

Indeed,  without  any  special  apparatus,  an  ordinary  tin- 
smith can  construct  a  pan  for  holding  the  metallic  salt 
to  be  vaporized  over  a  spirit-lamp,  which,  with  a  kettle 
of  boiling  hot  water  by  its  side,  furnishes  all  required 
accessories. 

Calomel  or  cinnabar  is  usually  selected  for  vaporiza- 
tion, and  often  the  two  in  combination — about  one-fourth 
more  of  the  latter  than  of  the  former  when  the  two  are 
commingled.  From  1  to  3  scruples  of  the  single  salt  or 
of  the  two  may  be  employed  at  a  sitting,  the  quantity 
being  estimated  not  merely  from  the  condition  of  the 
patient  but  from  the  size  of  the  chamber  to  which  steam 
is  admitted,  since  much  more  may  be  used  in  the  large 
receptacles  of  the  bath-houses  than  in  the  extemporized 
blanket  or  ticking  tent  which  may  be  employed  by  a 
country  physician  at  the  bedside  of  his  patient.  The 
exposure  should  last  for  about  half  an  hour — less  if  the 
patient  becomes  faint  during  the  steaming.  As  a  rule, 
the  subject  of  the  disease  should  be  fasting  at  the  bath- 
hour,  which  is  preferably  that  preceding  his  or  her  accus- 
tomed hour  of  sleep.  As  it  is  by  no  means  rare  for  the 
subject  to  become  faint,  it  is  well  to  have  a  stimulant  at 
hand,  and,  even  in  sending  patients  to  the  bath-houses, 
to  advise  the  carrying  with  them  of  a  small  flask  of  sherry 
or  brandy.  A  bath  every  third  or  even  every  second  day 
is  sufficient  save  in  cases  of  emergency — as,  for  example, 
when  there  has  been  ignorance  of  the  nature  of  the 
disorder  before  the  first  consultation,  and  the  patient  has 
a  highly  disfiguring  facial  exanthem  forbidding  his  or 
her  customary  association  with  family  or  friends.  In  such 
event,  and  for  brief  periods  of  time,  a  bath  may  be  taken 
daily;  but  in  these  cases,  as  well  as  in  the  others,  it  is 
needful  to  remember  that  the  patient  is  often  debilitated 
by  the  steaming,  even  when  vastly  improving  in  the  mat- 
ter of  the  removal  of  the  lesions  which  place  his  case  in 
the  emergency  class.  These  emergency  cases,  further- 
more, are  often  those  of  patients  suffering  from  febrile 
reactionary  symptoms  (syphilitic  fever),  and  the  need  of 


TREATMENT  OF  SYPHILIS.  237 

ferruginous  tonics,  of  quinine  in  ample  doses,  and  even 
of  a  generous  glass  of  wine  with  the  dinner,  should  not 
be  forgotten.  Local  mercurial  fumigation  by  means  of 
the  apparatus  sold  in  the  shops  is  of  value  in  many- 
cases  for  direct  application  of  the  vapor  both  to  the  skin 
and  the  mucous  cavities.  We  have,  however,  practically- 
limited  our  use  of  this  method  to  the  nasal  passages, 
where  its  value  is  without  question.  In  country  practice, 
where  apparatus  of  the  desired  sort  is  not  immediately 
at  hand,  a  hot  flat-iron  and  a  paper  cone  answer  admir- 
ably for  directing  mercurial  fumes  into  the  nasal  pas- 
sages. The  dose  of  calomel  or  of  cinnabar  selected  for 
local  fumigation  must  be  reduced  considerably  from  that 
used  in  the  general  bath.  For  the  nose  from  2  to  5 
grains  of  calomel  may  be  vaporized ;  for  the  face  a 
somewhat  larger  dose  may  be  used. 

Hypodermatic  Injection. — This  method  of  introducing 
mercury  into  the  system  is  properly  described  after  the 
others,  since,  as  a  matter  of  practical  experience,  it  is  not 
only  employed  far  less  often  than  others,  but  promises 
to  be  reserved  at  no  distant  date  for  use  only  in  special 
cases.  By  it  the  metal,  pure  or  in  combination,  is  in- 
jected directly  beneath  the  integument. 

The  advantages  of  this  method  are  rapidity  of  effect, 
the  sparing  of  the  digestive  tract  (a  feature  which  it 
shares  with  both  fumigation  and  inunction),  its  simplicity 
and  cleanliness  as  contrasted  with  the  two  methods 
named,  and  its  surrender  of  the  dosage  into  the  hands 
of  the  practitioner,  and  of  him  only — a  feature  of  im- 
portance. Other  advantages  claimed,  but  not  yet 
demonstrated  to  the  satisfaction  of  experts,  are  the  speed 
with  which  it  effects  a  radical  cure,  the  failure  of  relapses 
in  the  cases  thus  treated,  and  the  exclusion  of  the 
gummatous  phases  of  the  disease.  The  objections  to 
the  method  are  great :  it  has  often  proved  dangerous, 
and  in  a  few  instances  fatal ;  it  is  liable  to  produce  fur- 
uncles, nodes,  abscesses,  sloughing,  and  other  lesions  at 
the  site  of  injection ;   it  is  likely  to  beget  an  overween- 


238      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

ing  confidence  on  the  part  of  both  physician  and  patient 
that  the  disease  is  in  course  of  radical  treatment,  while 
precious  time  is  lost  that  might  have  been  employed  in 
protecting  the  victim  of  the  malady  from  its  ravages  at  a 
future  epoch.  We  have  occasionally  had  severe  fainting 
fits  follow  the  use  of  the  needle,  resulting  in  prostration 
of  the  patient. 

If,  nevertheless,  a  hypodermatic  mercurial  treatment 
be  selected,  too  much  care  cannot  be  taken  in  the  prep- 
aration of  the  skin  and  the  instruments  before  the  oper- 
ation. Only  sterilized  solutions  should  be  employed, 
and  the  skin  over  the  region  of  introduction  should  first 
be  cleansed  thoroughly  with  warm  water  and  soap,  then 
dried,  then  washed  with  alcohol  and  dried,  and  then 
moistened  with  a  I  :  1000  solution  of  the  sublimate. 
The  needle  employed  should  be  of  steel,  gold,  or  silver, 
somewhat  longer  than  that  of  the  ordinary  instrument, 
and  in  an  aseptic  state — as  also,  needless  to  add,  should 
be  the  hands  of  the  operator.  The  region  most  often 
selected  for  injection  is  the  post-trochanteric,  with  the 
patient  reclining  on  his  belly  and  the  muscles  completely 
relaxed.  The  needle,  with  syringe  attached  and  charged, 
taken  from  a  5  per  cent,  carbolized  bath  in  a  tray,  should 
be  pushed  slowly  down  to  the  region  where  the  salt  is 
to  be  deposited,  the  physician  avoiding  always,  first, 
entrance  to  a  vein  (known  by  the  ease  with  which  the 
syringe  begins  to  discharge  its  contents,  as  contrasted 
with  the  obstruction  encountered  in  muscle),  next,  re- 
gions of  unusual  pressure  or  friction,  and,  lastly,  the 
inferior  portion  of  the  derma  or  very  near  the  panniculus 
adiposus,  where  severe  sloughing  may  follow. 

The  damage  resulting  from  hypodermatic  injections 
of  mercury  may  be  the  formation  of  nodes,  abscesses, 
erythematous  patches,  and  sloughing  at  the  site  of  the 
deposit ;  alarming  cardiac  and  pulmonary  symptoms 
after  injection  within  a  vein ;  sudden  death  ;  exhaustion 
coming  on  slowly  after  the  operation ;  considerable  pain, 
at  times   agonizing,   at  the   site   of  the    puncture;    and 


TREATMENT  OF  SYPHILIS.  239 

salivation,  with  other  systemic  signs  of  the  toxic  action 
of  the  medicament.  In  well-managed  cases,  however, 
it  is  to  be  admitted  that,  with  a  properly  constituted 
solution  and  with  due  precautions,  hundreds  of  injections 
have  been  given  with  no  untoward  consequences. 

A  great  amount  of  literature  exists  on  the  subject 
of  hypodermatic  injections  of  mercury  for  relief  of 
syphilis,  and  the  list  given  of  selected  articles  employed 
for  the  purpose  is  intended  to  serve  chiefly  as  an  index. 

Soluble  Salts  of  Mercury.  —  Corrosive  sublimate  is 
employed  for  hypodermatic  injections  in  the  strength  of 
from  Y2  to  ^  grain,  dissolved  in  a  few  minims  of  water 
suspended  in  olive  oil,  or  emulsified,  as  with  vaseline  or 
mucilage.  The  injections  may  be  made  as  often  as  once 
every  second  or  third  day.  The  following  are  practi- 
cable formulae : 


iy.    Hydrarg.  chlor.  corros., 

gr-j; 

Glycerin., 

Aq.  dest, 

da.  f.5j. — M. 

Sig.  Inject  10  minims. 

ty.    Hydrarg.  chlor.  corros., 

gr-  ii 

Sod.  chlor., 

gr- 1; 

Aq.  dest., 

fsj— M. 

Sig.  Inject  60  minims. 

Jfy.     Hydrarg.  chlor.  corros., 

gr.  x; 

Acid,  tartar., 

3ss; 

Aq.  dest., 

fSj.— M. 

Sig.  Inject  10  to  12  minims. 

Other  preparations  of  this  group  are  the  following : 
Aspar agin- mercury.  —  2\  drachms  of  asparagin  are 
dissolved  in  warm  water,  and  a  saturated  solution  is 
made  with  the  mercuric  oxide ;  this  solution  is  filtered 
and  diluted  to  a  2  per  cent,  mercuric  solution,  and  \ 
grain     of    mercury     is     injected.     The    succinhnide    of 


240      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

mercury  is  injected  in  5  per  cent,  aqueous  solution,  so 
that  from  -^  to  -^  grain  is  employed  at  a  dose.  The 
oxycyanide  of  mercury  is  injected  in  doses  of  15  grains, 
containing  a  trifle  more  than  1  per  cent,  of  the  metal. 
Bamberger's  mercuric  albuminate  ;  Martineau's  mercuric 
peptonate ;  Sta?tb,s  mixture  of  mercury,  chloride  of 
ammonium,  chloride  of  sodium,  and  albumin ;  and 
Gaillard's  combination  of  mercuric  biniodide  and  sodium 
phosphate,  are  all  too  unstable  to  be  worthy  of  reliance. 
Nourry's  formula  for  the  iodo-tannate  is  as  follows  : 


^ 

Hydrargyri, 

gr-ro; 

Iodini, 

gr-  i; 

Acid,  tannic, 

gr-  TU> 

Glycerin., 

gtt.  XV- 

-M 

Other  soluble  preparations  which  have  been  recom- 
mended are  the  carbolate  of  mercury  (^  to  \  grain  for 
injection),  the  formamide  in  I  per  cent,  solutions,  the 
alaninate,  and  the  benzoate,  each  of  which  has  its 
partisans,  and  none  of  which  has  succeeded  in  achieving 
a  large  usage  at  the  hands  of  experts. 

Insoluble  Salts  of  Mercury. —  Calomel,  \  to  3  grains 
suspended  in  a  chloride-of-sodium  solution,  in  mucilage, 
in  glycerin,  or  in  oil,  has  been  injected  every  five  to  ten 
days,  as  well  as  metallic  mercury,  from  5  to  20  grains  in 
a  similar  vehicle. 

Oleum  cincreiim  (gray  oil)  is  made  by  emulsifying 
lanolin  and  chloroform  and  adding  metallic  mercury  in 
double  the  quantity  of  the  unguent :  20,  30,  and  50  per 
cent,  ointments  are  compounded  with  this  basis,  by  the 
addition  of  olive  oil.  From  \  to  I  grain  of  the  50  per 
cent,  solution  has  been  injected  once  or  twice  weekly, 
with  progressively  increasing  intervals  between  the  in- 
jections. Yellow  oxide  of  mercury  has  been  added  to 
mucilage  or  olive  oil  and  injected  so  that  from  I  to  2 
grains  have  been  used  at  a  single  dose.  The  black  oxide 
of  mercury  is  employed  in   10  per  cent,  oil,  in  glycerin, 


TREATMENT  OF  SYPHILIS.  24 1 

and  in  gum  emulsions ;  and  cinnabar,  in  the  strength  of 
1  grain  suspended  in  oil. 

The  conclusions  which  it  is  safest  to  accept,  after 
reviewing  the  subject  of  hypodermatic  injections  in 
syphilis,  have  been  well  summarized  .by  Dr.  White  of 
Philadelphia,  who  took  pains  to  collate  the  opinions  of  a 
number  of  American  experts  on  this  question.  The 
method  has  not  as  yet  shown  results  which  warrant  its 
adoption  as  a  means  of  routine  treatment  to  the  exclu- 
sion of,  or  in  preference  to,  others ;  it  has,  on  the  con- 
trary, some  apparently  insuperable  disadvantages  and 
even  dangers,  which  render  it  improbable  that  it  will 
ever  be  generally  adopted. 

The  Toxic  Effects  of  Mercury  (Hydrargyrism  ;  Saliva- 
tion ;  Mercurial  Pains,  etc.). — Like  most  medicinal  agents 
of  well-marked  efficacy,  mercury,  when  improperly 
administered  or  when  administered  to  peculiarly  suscep- 
tible subjects,  may  produce  toxic  effects.  Some  of  these 
effects  ensue  rapidly  (so-called  "  acute "  symptoms), 
others  more  slowly  (the  "  chronic  ").  One  of 'the  most 
common  and  unpleasant  of  these  results  is  salivation,  an 
accident  displayed  in  many  grades.  In  the  slightest 
grade  there  is  moderate  fetor  of  the  breath  ;  slight  in- 
spissation  of  the  saliva ;  some  tenderness  of  the  teeth, 
more  particularly  of  the  molars  when  brought  together; 
a  sponginess  of  the  gums,  which  bleed  readily  when 
pressed  upon ;  a  metallic  taste  in  the  mouth ;  and  a 
peculiar  pasty  aspect  of  the  dorsum  of  the  tongue,  this 
organ  often  exhibiting  further  the  imprint  of  the  molar 
teeth  upon  its  free  edges.  All  these  symptoms  may  be 
exaggerated  in  various  grades  to  the  point  where  the  paro- 
tid and  submaxillary  glands  become  tender  and  tumid,  the 
saliva  flows  in  a  full  stream  from  the  mouth,  the  teeth  are 
loosened  and  fall,  the  mucous  membrane  of  the  mouth 
becomes  swollen  and  often  eroded  in  patches,  the  tongue 
is  swollen  and  protruded,  and  ulcerated,  and  the  bones  of 
the  jaw  are  necrosed.  The  breath  in  all  cases  has  an 
unmistakable  and  nauseous  odor,  and  the  patient  is  also 

16 


242      SYPHILIS  AND    THE  VENEREAL    DISEASES. 

generally  in  a  depressed  condition  of  mind  and  disturbed 
in  most  of  the  bodily  functions. 

Among  the  results  that  develop  more  slowly  may  be 
named  many  of  the  evidences  of  gastro-intestinal  dys- 
pepsia (inappetence,  eructations,  heartburn),  progressive 
adynamia  and  anaemia,  pains  in  the  joints,  occasionally 
limited  to  one  of  the  larger  joints  and  associated  with 
temporary  immobility  from  pain,  and  symptoms  simu- 
lating those  of  muscular  rheumatism.  While  there  is  a 
large  list  of  ailments,  not  here  set  down,  popularly  ac- 
credited to  the  toxic  effects  of  mercury,  it  may  be  said 
of  most  of  such  symptoms  that  they  are  due  either  to 
syphilis  or  to  some  other  cause,  and  are  wrongly  imputed 
to  the  action  of  the  metal.  We  have  never  been  able  to 
persuade  ourselves  that  for  any  reasonable  period  after 
the  ingestion  of  mercury  had  been  suspended  (months  at 
the  longest)  any  general  effects  of  it  are  perceptible  in  a 
previously  healthy  subject ;  and  the  records  of  the  physi- 
cians in  charge  of  the  laborers  in  mercury-mines  attest 
the  same  fact.  There  the  toxic  effects  are  distinct  and 
often  grave,  severe  salivation  being  more  or  less  rapidly 
followed  in  all  grave  cases  by  osseous  necrosis.  Nothing 
is  found  in  these  records  corresponding  with  the  "  chronic 
rheumatic  disorders,"  "  eruptions  upon  the  skin,"  and 
other  ailments  popularly  charged  to  a  continued  use  of 
mercury,  and  occurring  years  after  its  suspension. 

Let  it  be  noted  further  that  in  the  few  cases  where, 
early  in  a  syphilitic  career,  mild  salivation  has  acci- 
dentally occurred  (the  writers  have  seen  but  few  cases 
in  many  years),  the  issue  is  not  altogether  without  its 
bright  side.  As  a  matter  of  fact,  the  few  salivated 
patients  have  in  the  results  obtained  compared  most 
favorably  with  others ;  and  in  one  specially  dangerous 
and  extreme  case,  where  salivation  was  intentionally  pro- 
duced, the  issue  was  in  the  highest  degree  satisfactory, 
as  a  valuable  life  seemed  thereby  to   have  been  saved. 

When  mercurial  stomatitis  supervenes,  with  symptoms 
of  salivation,  the  metallic   dose,  if  the   case  is   not   ex- 


TREATMENT  OF  SYPHILIS.  243 

ceedingly  urgent,  should  at  once  be  suspended  and  the 
diet  be  limited  to  nutritious  foods  in  a  liquid  or  a  semi- 
liquid  state  (broths,  cream,  soft-boiled  eggs,  etc.).  The 
fluids  used  for  drinking  should  be  neither  hot  nor  cold, 
and  all  salted,  spiced,  and  acetous  articles  of  diet  should 
be  forbidden.  The  mouth  should  be  washed  frequently 
with  bland  lotions  of  flaxseed  tea  or  borated  or  car- 
bolated  fluids,  always  diluted,  such  as  : 

Ify.  Potass,  chlorat.,  3j ; 

Mel.  despum., 

Myrrh,  tinct.,  da.  fsss  ; 

Aq.  dest.,  ad  fsviii. — M. 

Sig.  To  be  used  as  a  mouth-wash  and  gargle,  diluted 
with  tepid  water  until  grateful  to  the  surface. 

Often  during  the  day  the  gums  should  be  rubbed 
gently  but  thoroughly,  within  and  without  the  circle 
of  the  teeth,  with  a  tepid  myrrh-and-cinchona  wash 
(equal  parts  of  the  tincture  of  each  suspended  me- 
chanically by  shaking  in  water)  applied  by  means  of 
a  soft  piece  of  linen  wrapped  about  the  forefinger.  We 
invariably  order  iron  internally  in  these  cases,  and  if 
any  specific  medication  is  employed  before  the  toxic 
effects  subside,  we  employ  in  small  doses  one  of  the 
salts  of  iodine.  Recovery  under  good  treatment  is  in 
any  well-managed  case  rapid  and  complete. 

Iodine  and  its  Compounds.  —  With  relation  to  the 
therapy  of  syphilis,  iodine  and  its  compounds  stand  next 
after  mercury  in  popular  estimation  ;  and  if  just  reserve 
be  made,  they  certainly  stand  in  this  relation  when 
properly  employed  in  selected  cases.  There  are  two 
axioms  that  still  very  largely  influence  the  minds  of  pro- 
fessional men  on  this  question :  one  is  that  while  mercury 
is  most  valuable  in  early  periods  of  syphilis,  the  com- 
pounds of  iodine  are  chiefly  valuable  in  the  late  or  gum- 
matous periods;  another  is  that  while  mercury  cures 
the  disease,  the  compounds  of  the   other  metal  relieve 


244      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

without  curing.  Both  axioms  are  imperfect  generaliza- 
tions of  a  wide  experience,  which  must,  however,  not  be 
permitted  to  warp  the  judgment  of  the  practitioner  in 
any  case  where  the  one  or  the  other  drug  is  chiefly  in- 
dicated. 

The  following  are  conditions  in  which  it  is  common, 
and  in  general  wise,  to  employ  the  iodine  compounds  : 

First :  In  all  attempts  to  resolve  gummatous  lesions 
promptly,  the  iodides  are  wellnigh  unequalled  in  the 
armamentarium  of  the  expert.  Here  (as  in  gummata  of 
the  brain,  the  testis,  the  liver,  the  spleen,  or  the  kidney) 
life  may  be  saved  by  their  efficient  employment,  and  in 
other  cases  (gummata  of  the  periosteum,  the  meninges, 
etc.)  a  great  amount  of  suffering  may  be  spared. 
Second :  The  iodides  are  often  in  the  highest  degree 
valuable  in  any  stage  of  syphilis  when  the  patient 
either  is  intolerant  of  mercury  or,  if  sufficiently  tolerant, 
cannot  be  made,  when  ingesting  it,  to  gain  in  weight,  in 
appetite,  and  in  the  proper  performance  of  his  functions. 
Third :  When  it  is  desired  to  produce  a  profound  im- 
pression on  a  syphilitic  lesion,  and  the  patient  is  being 
subjected  to  the  action  of  mercury  by  any  of  the  methods 
of  its  external  employment  (fumigation,  inunction,  etc.). 
Fourth  :  The  iodides  are  in  some  cases,  not  as  a  routine 
treatment,  valuable  as  furnishing  an  alternate  medication 
of  patients  long  subjected  to  the  action  of  mercury. 

It  is  exceedingly  doubtful  if,  as  was  once  thought,  the 
iodide  of  potassium  aids  in  the  elimination  of  mercury 
previously  introduced  into  the  system.  The  speedy 
effects  of  the  salt  are  well  known,  and  its  rapid  appear- 
ance in  the  urine  after  ingestion  (as  shown  by  starch  and 
other  tests)  is  readily  demonstrable.  When  the  patient 
is  under  its  influence  the  application  of  starch  to  the 
tongue  produces  there  a  blue  color,  and  the  nitrate  of 
silver  a  yellowish  tinge,  as  a  consequence  of  the  result- 
ing double  decomposition. 

The  brilliant  results  which  the  iodides  in  selected 
cases  are  capable  of  accomplishing,  and   the  dread  of 


TREATMENT   OF  SYPHILIS.  245 

producing  ill  effects  by  the  action  of  mercury,  have 
buttressed  the  great  popularity  of  the  former  with  the 
general  practitioner  and  with  the  public.  Iodine  and  its 
compounds  are  represented  in  almost  all  the  proprietary 
preparations  sold  in  the  shops  for  the  relief  of  syphilis. 
Iodine  is  the  one  remedy  earliest  and  most  often  resorted 
to  by  the  ignorant,  and  it  is  the  one  which  is  last  used, 
and  then  most  effectively,  by  the  expert.  Given  the 
patient  who  has  been  relieved  of  syphilis  without  a  resort 
to  iodine,  and  his  case  has  probably  been  managed  better, 
and  is  more  secure  as  to  its  future,  than  that  of  another 
in  which  a  large  use  has  been  made  of  the  iodine  salts. 

The  best  known  preparations  are  the  iodides  of  potas- 
sium, sodium,  lithium,  strontium,  starch,  and  rubidium ; 
but  the  iodide  of  potassium  has  long  held  its  own  at  the 
head  of  the  list,  and  it  gives  promise  of  doing  so  for 
years  to  come.  While  given  often  in  combination  with 
other  drugs,  it  is  by  no  means  settled  that  these  combi- 
nations (save  with  mercury,  as  described  later)  possess 
any  value  over  the  simpler  solutions.  Of  these  solu- 
tions, none  is  better  than  that  made  by  adding  an 
ounce  of  the  iodide  of  potassium  to  a  fluidounce  of  dis- 
tilled water ;  but  as  this  combination  often  deposits  the 
salt  by  precipitation  about  the  cork  of  the  vial  after  a 
brief  interval,  and  as  it  is  at  times  somewhat  difficult  of 
digestion,  the  iodide  is  often  administered  in  drop  doses 
from  a  solution  made  by  adding  half  an  ounce  of  the 
potassic  salt  to  an  ounce  of  the  essence  of  pepsin  (Fair- 
child's  or  another).  The  first  formula  has  the  advantage 
that  it  may  be  given,  when  that  article  of  food  does  not 
disagree  with  the  patient,  in  milk  as  well  as  in  water. 

The  dosage  of  the  iodide  depends  almost  wholly  on 
the  emergency  presented  in  any  case  where  it  is  thought 
best  to  employ  it.  In  uncomplicated  cases  it  may  be 
administered  in  teaspoonful  doses  of  a  solution  contain- 
ing 5,  10,  or  20  grains  to  the  drachm;  but  in  cases 
where  an  emergency  has  arisen  it  is  customary  with  ex- 
perts to  order  one  of  the  stronger  solutions  named  above, 


246      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

and,  beginning  with  drop  doses,  to  increase  gradually 
either  one  drop  per  diem,  or  one  or  even  two  or  more 
drops  each  dose,  until  much  larger  doses  are  reached 
than  are  usually  employed  in  cases  where  no  emergency 
exists.  In  these  cases  large,  and  even  extremely  large, 
doses  are  slowly  reached  and  for  long  periods  of  time 
steadily  maintained.  In  this  way  300,  400,  600  grains, 
and  even  more,  of  the  iodide  of  potassium  have  been 
given  in  twenty-four  hours,  and  with  favorable  results  as 
respects  the  object  in  view.  In  reaching  the  larger 
doses  the  following  rules  should  be  observed  :  (a)  The 
dose  should  not  be  increased  after  the  occurrence  of  any 
of  the  serious  symptoms  of  iodism,  described  later ;  (b) 
nor  if  constipation  of  a  marked  character  occurs  ;  (c)  nor 
if  any  decided  indication  of  trouble  occurs  in  the  urine 
(albuminuria,  etc.) ;  (d)  nor  if  the  immediate  effect  in 
view  is  secured  (relief  of  a  dangerous  cephalalgia  in 
syphilitic  meningitis  ;  relief  of  torturing  pain  at  night 
from  an  osteoperiostitis,  etc.). 

The  articles  added  to  solutions  of  the  iodide  of  potas- 
sium with  a  view  to  improve  its  efficiency  or  to  prevent 
iodism  are  yearly  accorded  less  and  less  favor,  though 
once  held  in  high  esteem.  Thus  the  chloride  of  am- 
monium in  doses  of  5  grains  and  the  carbonate  of  am- 
monium in  doses  of  10  grains  were  thought  to  increase 
the  efficiency  of  the  iodine  salt,  while  arsenic  and  arseni- 
ous  acid  were  added  with  a  view  to  the  prevention  of 
iodic  acne. 

A  great  number  of  remedies,  mostly  from  the  vege- 
table kingdom,  have  been  extolled  for  years  as  not  merely 
of  themselves  sufficient  to  "  cure  "  the  disease,  but,  fail- 
ing that,  to  add  to  the  value  of  the  iodide  of  potassium 
by  assisting  in  its  assimilation  and  by  giving  tone  to  the 
stomach.  It  would  be  a  waste  of  space  to  enumerate 
these  remedies,  beginning  with  sarsaparilla,  which  even 
at  this  late  day  still  holds  sway  over  the  minds  of  the 
credulous,  and  ending  with  the  "  McDade "  formula: 


TREATMENT  OF  SYPHILIS.  247 

Yy.  Smil.  sarsaparilla,  fl.  ext., 
Stilling,  sylvat,  fl.  ext., 
Kappse  minor.,  fl.  ext., 
Phytolacc.  decand.,  fl.  ext,    da.  fsij ; 
Xanthoxyl.  Carolin.,  tinct,  fsj. — M. 

Sig.  Teaspoonful  to  tablespoonful  doses  in  water  before 
food. 

None  of  these  "  vegetable  "  remedies  can  be  demon- 
strated to  have  any  curative  effect  upon  syphilis,  apart 
from  the  metallic  salts  with  which  it  is  usual  to  com- 
pound them.  They  are  never  ordered  by  the  writers, 
for,  if  merely  a  tonic  and  carminative  effect  be  desired, 
much  more  valuable  remedies  are  available.  Strychnia, 
quinine,  and  iron  or  the  mineral  acids,  the  latter  often 
in  conjunction  with  a  mild  mercurial,  are  superior  from 
every  point  of  view  to  all  of  the  "  vegetable  infusions 
and  decoctions." 

The  fluid  extract  of  coca,  much  praised  by  Taylor, 
stands  on  a  different  footing,  since  it  is  not  claimed  ina 
any  sense  to  be  a  specific  for  the  disease,  but  only  a 
valuable  agent  in  exerting  a  tonic  effect  upon  the  ner- 
vous, vascular,  and  lymphatic  systems.  We  have  used 
the  coca  in  many  cases  with  great  advantage  both  in 
the  form  of  the  wine  (Mariani,  Metcalf)  and  in  that  of 
the  fluid  extract,  as  follows  : 

I^.  Erythrox.  coc,  fl.  ext.,  fsij ; 

Gentian.,  tinct.  co., 

Cinchon.,  tinct.  co.,  da.  fsj ; 

Elix.  calisayas,  fs*iv. 

Sig.  A  tablespoonful  in  water  after  food. 

1^.   Erythrox.  coc,  fl.  ext,  f  |ij ; 

Cinchon.,  tinct.  co., 

Gentian.,  tinct.  co.  da.  fsij. 

Sig.  Two  teaspoonfuls  in  water  after  food. 

Toxic  Effects  of  the  Iodine  Compounds. — Iodism,  or  the 


248      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

symptoms  of  toxic  effects  after  the  ingestion  of  the  com- 
pounds of  iodine,  is  much  more  frequent  than  the  pro- 
duction of  toxic  effects  by  mercury,  on  account  of  the 
rapidity  with  which  iodine  affects  the  system,  and  also 
on  account  of  the  far  larger  number  of  persons  suscep- 
tible to  such  effects.  In  discussing  this  subject  it  may 
for  practical  purposes  be  assumed  that  the  iodide  of 
potassium  is  the  remedy  selected,  seeing  that  it  is  the 
most  commonly  ingested  of  all  the  iodine  compounds 
employed  in  the  treatment  of  syphilis. 

Like  all  drugs  exerting  in  any  degree  a  toxic  effect, 
the  iodide  of  potassium  will  often  display  its  mischievous 
energy  after  but  a  small  dose  has  been  administered — 
even  so  small  as  1  or  2  grains.  In  other  cases  the  toxic 
results  are  declared  only  when  very  large  doses  are 
reached.  It  is  the  popular  and  semi-professional  belief 
that  some  persons  have  a  special  idiosyncrasy  forbidding 
them  ever  to  make  use  of  the  drug,  but  that  in  many 
patients,  by  care  and  a  skilful  adjustment  of  the  dose, 
there  can  be  established  a  "toleration"  which  will  enable 
the  vast  majority  to  ingest  even  the  largest  quantities. 
There  is  truth,  probably,  on  both  sides  of  this  question, 
though  its  final  determination  is  difficult.  With  the 
employment  of  the  graduated  dose,  with  the  bowels 
freed  from  irritating  contents,  with  the  habits  of  life 
regulated  as  carefully  as  they  always  should  be  in  the 
subject  of  syphilis,  the  end  sought  can  generally  be 
attained.  The  toxic  symptoms  of  iodism  may  be  of  the 
very  slightest  grade  (the  occurrence  of  one  or  two  irri- 
table nodules  over  the  face),  or  they  may  have  grave 
sequences  which  may  be  in  the  highest  degree  alarming. 

It  has  been  said  of  the  iodide  of  potassium  that  it  is 
capable  of  producing  upon  the  skin  a  picture  resembling 
that  of  every  cutaneous  affection,  and  this  statement  is 
certainly  suggestive  of  an  interesting  series  of  facts.  The 
lesions  produced  in  the  skin  are  usually  of  the  acne 
type,  and  limited  to  the  face,  the  shoulders,  the  neck, 
and  the  upper  portion  of  the  trunk — the  regions  chiefly 


TREATMENT   OF  SYPHILIS.  249 

affected  by  the  disease  named.  Classified,  they  range 
between  macules  and  papulo-pustules,  tubercles,  nodes, 
bullae,  and  phlegmonous,  purpuric,  and  ulcerative  lesions. 

Other  symptoms  are  the  production  of  a  metallic  taste 
in  the  mouth,  salivation,  coryza  of  a  persistent  type  (often 
with  an  exceedingly  abundant  serous  discharge  from  the 
nares),  and  several  forms  of  urticaria,  verging  in  ex- 
treme cases  to  the  type  of  angioneurotic  oedema,  with 
spasm  of  the  glottis  when  the  swellings  occur  in  this 
region,  dyspnoea,  and  involvement  of  the  joints.  In  other 
cases  all  the  symptoms  of  peritonitis  are  present,  with 
tumefaction  of  the  belly,  intense  pains,  constipation,  and 
fever.  Other  toxic  effects  are  slower  of  evolution, 
and  are  exhibited  in  a  progressive  anorexia,  weakness, 
decolorization  of  the  skin  (of  anaemic  type),  and  decided 
loss  of  sexual  desire  and  vigor.  As  a  rule,  the  toxic 
effects  of  the  iodide  of  potassium  speedily  disappear 
when  the  exhibition  of  the  remedy  is  suspended  and 
one  of  the  tonic  methods  of  treatment  is  substituted. 
When  the  anaemia  from  long-continued  use  of  the  iodide 
is  added  to  the  cachexia  of  syphilis,  the  result  is  espe- 
cially unfortunate,  and  only  the  clear  eye  of  an  ex- 
perienced physician  can  precisely  discriminate  between 
the  two. 

Mixed  Treatment. — The  term  "  mixed  treatment "  has 
been  employed  to  designate  the  method  by  which 
mercury  and  the  iodine  salts  are  employed  in  combina- 
tion in  the  treatment  of  syphilis.  It  is  obvious  that  they 
may  be  administered  simultaneously  when  mercury  is 
introduced  either  by  inunction,  by  fumigation,  or  by 
hypodermatic  injection,  and  the  iodides  are  at  the  same 
time  given  by  the  mouth ;  also  when  at  one  time  in  the 
day  a  mercurial  and  at  another  an  iodide  dose  is 
ordered ;  and,  lastly,  when  mercury  and  a  salt  of  iodine 
are  administered  at  the  same  time  in  a  single  dose.  It 
is  for  the  combination  last  named  that  the  title  "  mixed 
treatment "  has  been  especially  reserved. 

The  following  are  a  few  of  the  "  mixed  "  formulae  most 


250      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

often  employed  toward  the  end  of  the  first  year  of 
syphilitic  treatment,  or  earlier  when  there  is  a  special 
indication  for  the  use  of  the  iodides,  as  when  gumma- 
tous, tubercular,  nodular,  or  threatening  lesions  persist 
upon  the  skin  or  over  the  mucous  membranes,  refusing 
to  yield  to  mercury  alone  : 

^j.    Hydrarg.  biniodid.,  grs.  j— iij  ; 

Potass,  iodid.,  Sss-ij ; 

Syr.  aurant.  cort,  fgiij  ; 

Aq.  dest.,       '  ad  f^vj. — M. 

Sig.  A  teaspoonful  in  a  wineglassful  of  water  after  food. 

At  times  the  bitter  tinctures  are  added  to  formulae  of 
this  character,  in  order  to  produce  a  tonic  effect ;  but,  as 
already  pointed  out,  it  is  in  general  better  in  syphilis  to 
administer  tonics  separately  and  before  meals,  seeing 
that  the  dose  of  the  tonic  remedy  is  commonly  fixed, 
while  it  is  often  of  service  to  administer  the  mercurial 
in  a  dose  that  can  be  changed  so  as  to  increase  or 
decrease,  when  required,  the  amount  of  the  metal  in- 
gested. 

The  decomposition  of  the  mercuric  bichloride  by  the 
iodide  is  often  practised  in  compounds  of  the  "  mixed  " 
class,  but  as  there  is  some  uncertainty  about  the  result 
in  different  solutions,  it  is  better  to  order  the  biniodide. 
Bichloride  combinations  with  iodide  of  potassium  are 
usually  made  as  follows  : 

1^.     Hydrarg.  bichlorid.,  gr.  j — iij ; 

Potass,  iodid.,  §ss-ij  ; 

Glycyrrhiz.,  syr.,  fsij ; 

Aq.  dest,  ad  fsvj. — M. 

Sig.  A  teaspoonful  in  water  after  food. 

The  Treatment  of  Syphilitic  Lesions  as  they  are 
Presented  in  the  several  Organs  of  the  Body. — The 

treatment  of  chancre  has  been  discussed  in  the  pages 
devoted  to  that  subject  (pp.  48-53). 

Syphilis  of  the  skin  is  amenable  to  the  treatment  appro- 
priate to  the  systemic  state,  but  at  times,  especially  when 


TREATMENT   OF  SYPHILIS.  2$  I 

the  lesions  are  localized  and  asymmetrical,  local  treat- 
ment is  of  especial  value. 

The  erythematous  and  papular  syphilodermata,  when 
persisting  on  the  exposed  surfaces  of  the  body  (face, 
hands,  etc.),  may  be  sponged  with  warm  water  at  night 
and  afterward  anointed  with — 

~Bf.  Hydrarg.  ammon.  (vel.  chlorid.  mit.),    gr.  v-xx  ; 
Bals.  Peruv.,  TTlx ; 

Unguent,  aq.  ros.,  Ij. — M. 

Sig.  External  use. 
Or,  when  a  lotion  is  preferred,  the  parts  may  be  sponged 
with  a  solution  of  the  bichloride  in   rose-water,  \  to    I 
grain  to  the  ounce  ;  or  the  following  may  be  used  : 
1^.  Hydrarg.  chlor.  corros.,       ,       gr.  ij ; 
Vin.  rect,  spt., 
Benzoin.,  tinct., 

Tolutan.,  tinct.,  da.  f 3j  ; 

Glycerin.,  f  3j ; 

Aq.  ros.,  ad  fsvj. — M. 

Sig.  Shake.     External  use. 
When    seborrhceic   crusts    form  about   the    forehead, 
nose,  lips,   ears,   etc.,  the   following  may  be  employed 
with  advantage  : 

1^.   Hydrarg.  sulph.  rub.,  gr.  j — ij  ; 

Sulph.  praecip.,  ,3J  ; 

Bals.  Peruv.,  tTlx  ; 

Unguent,  aq.  ros.,  |j. — M. 

Sig.  External  use. 
Vaseline  should  be  ordered  as  a  salve-basis  when  the 
unguent  is  to  be  applied  over  a  hairy  region.     Resorcin 
is  useful,  in  the  strength  of  from  a  scruple  to  a  drachm ' 
of  ointment. 

For  the  papular  and  scaling  lesions,  which  are  often 
obstinate,  especially  over  the  palms  and  the  soles,  noth- 
ing is  better  than  mercurial  ointment  in  full  strength,  or, 
in  regions  where  the  skin  is  tender,  in  the  strength  of 
one-half,   one-quarter,  or   less.     The   mercurial  plasters 


252      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

and  plaster-mulls  may  be  employed  with  advantage 
in  many  cases.  Lesions  of  the  palms  and  the 
soles,  when  persistent,  require  preliminary  softening 
with  warm  water  and  green  soap,  the  parts  being  well 
shampooed,  especially  at  night,  before  the  application 
of  the  salve,  the  latter  being  kept  in  contact  with  the 
skin  during  the  hours  of  sleep.  The  ointment  of  the 
nitrate  of  mercury  in  the  strength  of  2  drachms  to  the 
ounce  may  often  be  added  with  good  effect  to  the 
Wilkinson  salve *  or  to  an  unguent  compounded  by 
adding  to  an  ounce  of  lard  from  \  to  1  drachm  of  one 
of  the  tars  (oleum  rusci,  oleum  cadini,  oleum  picis)  and 
from  1  to  2  drachms  of  precipitated  chalk,  the  whole 
being  compounded  secundum  artem  by  boiling,  sifting, 
and  stirring.  The  articles  found  useful  in  non-syphilitic 
papular  and  scaling  lesions  (chrysarobin,  salicylic  acid, 
and  ichthyol)  may  here  also  often  be  used  with  profit. 
The  soothing  salves  (diachylon  ointment,  oleate  of 
bismuth,  and  benzoinated  zinc  ointment  freshly  prepared) 
may  also  be  used,  adding,  to  the  latter  particularly,  the 
mercurial  specially  indicated. 

Condylomata,  secreting  papules,  warts,  vegetations, 
etc.  about  the  ano-genital  parts  and  over  the  axillae,  the 
groins,  and  elsewhere  are  readily  relieved.  They  are  all 
foul-smelling,  and  they  require  deodorizing  solutions  of 
chlorinated  soda  or  of  boric  acid,  after  which  they  are 
to  be  dusted  thoroughly  with  equal  parts  of  calomel  and 
starch  or  with  boric  acid.  The  apposed  surfaces  are 
to  be  separated  by  the  interposition  of  antiseptic  lint. 

1  R  .  Sulphuris  sublimat, 

01.  rusci,  da.  £ij ; 

Sapon.  virid., 

Adipis,  da.  §ss ; 

Cretae  praeparat.,  gr.  lxxv. — M. 

Sig.  External  use. 

The  best  oleum  rusci  should  be  used  in  preparing  this  ointment ;  but  if 
the  best  cannot  be  obtained,  either  the  oleum  picis  or  the  oleum  cadini 
may  be  substituted  for  it.  If  possible,  use  the  oleum  rusci  having  the 
peculiar  odor  of  Russian  leather. 


TREATMENT   OF  SYPHILIS.  2$$ 

For  the  dusting-powder  named  may  be  substituted  euro- 
phen  (which  is  usually  very  comforting  in  its  relief  of  the 
odor  and  the  pruritic  condition),  hydronaphthol,  or  iodol. 
Where  the  warty  growths  are  exuberant  they  may  be 
painted  with  solutions  of  the  bichloride  in  flexile  col- 
lodion, y2  scruple  to  the  ounce,  or  with  a  modification 
of  the  well-known  wart-cure  formula : 

Tfy.  Acid,  salicylic,  9j-3J  J 

Extr.  cannabis  indie,  Bss-j  ; 

Collodion,  flexil.,  gj—  M. 
Sig.  To  be  painted  over  the  part. 

By  thorough  treatment  with  these  and  similar  solu- 
tions it  will  very  rarely  be  necessary  to  employ  severer 
measures.  The  actual  cautery,  the  curette,  and  the 
several  caustics  may,  indeed,  be  employed,  but  in  general 
this  course  indicates  a  lack  of  skill  on  the  part  of  the 
physician  in  his  employment  of  the  simpler  measures. 

Pustular  lesions,  crusted  or  ulcerated,  especially  over 
the  face,  require  careful  attention,  since  the  production  of 
scars  in  this  region  may  mark  the  patient  for  life.  It  is 
well  to  remember,  in  the  management  of  all  such  emer- 
gencies, that  they  represent  a  mixed  infection,  and  that 
the  staphylococci  are  to  be  combated.  All  crusts  should 
be  removed  by  repeated  hot  borated  washings,  after 
which  the  surface,  if  thoroughly  cleansed,  may  first  be 
wiped  with  alcohol,  or  with  a  2  per  cent,  formaline  solu- 
tion, or  touched  with  a  solution  of  the  following  sort : 

1^.   Hydrarg.  chlor.  corros.,          gr.  j-ij ; 
Benzoin.,  tinct.,  foj. — M. 

Sig.  For  external  use  only. 

One  of  two  courses  may  then  be  pursued:  The  skin-sur- 
face may  be  dusted  with  calomel,  europhen,  boric  acid, 
or  hydronaphthol,  and  over  all  there  may  be  applied  a 
delicate  film  of  cotton  fastened  at  the  edges  to  the  sur- 
face with  a  light  layer  of  flexible  collodion  ;  or  face- 
plaster  may  be  superimposed  over  the  cotton ;  or  a  film 


254      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

of  collodion  may  be  applied  over  the  powder  directly. 
An  alternate  course  is  to  apply  as  a  dressing  one  of  the 
mercurialized  pastes  :  a  little  practice  will  suggest  from 
day  to  day,  to  both  practitioner  and  patient,  which  paste 
best  serves  the  special  indications.  From  I  to  20  grains 
of  ammoniated  mercury  or  calomel  may  be  added  to  the 
Lassar  paste  (the  formula  for  which  has  already  been 
given),  or  1  or  2  drachms  of  mercurial  ointment,  each  in 
place  of  the  salicylic  acid  usually  ordered  in  the  combi- 
nation named. 

When  pustular  or  gummatous  lesions  of  either  the 
skin  or  the  subcutaneous  tissue  break  down  to  form  a 
syphilitic  ulcer,  the  treatment  in  each  event  is  the  same. 
All  crusts  are  to  be  removed  thoroughly — if  need  be,  by 
soaking  and  washing  in  hot  borated  water,  followed  by 
the  use  of  a  formaline  solution,  as  described  above — all 
sloughs  are  to  be  plucked  away  or  curetted,  and  the 
surface  is  to  be  made  as  clean  as  possible.  The  floor 
and  the  edges  of  the  ulcer  are  then  freely  and  deeply 
cauterized  either  with  the  nitrate  of  silver  in  stick  or 
in  solution  or  with  fuming  nitric  acid.  Delay  should 
be  made  in  the  after-dressing  until  all  oozing  has  ceased, 
after  which  one  of  the  powders  is  to  be  applied,  followed 
by  an  antiseptic  compress  and,  when  practicable,  a  band- 
age. The  latter  is  chiefly  valuable  over  the  lower  ex- 
tremities, where  support  is  as  imperatively  required  for 
most  syphilitic  ulcers  as  for  those  of  eczemato-varicose 
type.  The  flannel  bandage  cut  on  the  bias  answers  well 
for  patients  unable  to  apply  skilfully  the  common  roller 
bandage  over  leg  or  arm ;  and  for  those  able  to  afford 
the  slightly  greater  expense  the  silk  elastic  stocking  is 
both  convenient  and  in  a  high  degree  useful  in  the  way 
of  support.  In  this  event  we  are  in  the  habit  of  order- 
ing for  use  next  the  skin,  by  both  sexes,  a  long  white 
cotton  stocking  such  as  is  usually  worn  by  women, 
the  elastic  silk  support  being  drawn  over  the  stocking. 

In  all  indolent  ulcerations  of  the  extremities  support  is 
readily  effected,  after  dusting  with  an  appropriate  powder, 


TREATMENT  OF  SYPHILIS.  255 

by  dressing  with  superimposed  strips  of  rubber  or  of 
adhesive  plaster  encircling  two-thirds  of  the  circumfer- 
ence of  the  limb.  Internally  the  treatment  of  these 
ulcers  is  best  conducted  by  the  "  mixed  "  method,  the 
iodide  being  usually  demanded  in  the  fullest  doses,  and 
the  mercurial  at  the  same  time  by  inunction  or  by  addi- 
tion to  the  iodide  by  the  mouth  in  one  of  the  "  mixed  " 
formulae. 

In  the  early  forms  of  syphilitic  alopecia  not  obviously 
due  to  changes  in  the  scalp,  it  is  well  to  clip  or  cut  the 
hair  short  and  to  shampoo  the  scalp  three  or  four  times 
in  the  week  with  the  tincture  of  green  soap  flavored 
with  lavender-water  or  cologne -water.  After  such 
shampooing,  and  also,  at  times,  when  none  is  employed, 
the  following  lotion  may  be  well  rubbed  into  the  sur- 
face: 

~Bf.  Cantharid.,  tinct,  fsj ; 

Hydrarg.  chlor.  corros.,  gr.  j-iij ; 

Capsici,  tinct., 

Ol.  sesami,  da.  f  sss  ; 

Spts.  vin.  rectif,  f §ij ; 

Aq.  ros.,  ad  fsviij. — M. 
Sig.  External  use  over  the  scalp. 
Or, 

1^.  Resorcin.,  §ss ; 

Spts.  vini  rectif.,  5ij  ; 

Glycerin.,  3j  ; 

Aq.  ros.,  ad  flvj. — M. 

When  crusts  form  upon  the  scalp,  they  should  be  re- 
moved by  the  shampoo ;  a  salve  may  often  afterward  be 
employed,  such  as  ammoniated  mercury  (or  calomel),  5 
grains  to  the  ounce  of  vaseline,  or  precipitated  sulphur 
1  drachm  and  cinnabar  1  grain  to  the  ounce  of  the  same 
salve-basis. 

In  the  management  of  syphilitic  lesions  of  the  mouth 
it  has  already  been  shown  that  prophylaxis  is  of  prime 


256      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

necessity.  The  exclusion  of  tobacco  in  every  form,  the 
stopping  of  all  carious  teeth,  and  the  removal  of  those 
requiring  extraction  should  be  secured  at  the  outset. 
The  chewing  of  gum,  the  constant  holding  in  the  mouth 
of  a  toothpick  which  is  practically  chewed,  and  even 
the  sharp  edge  of  a  sound  tooth  against  which  the 
tongue  plays,  may  each  be  responsible  for  a  deeply 
extended  ulcer.  All  mucous  patches  should  be  touched 
daily,  or  twice  daily  when  practicable,  with  either  a  5-, 
a  10-,  or  a  20-grain  solution  of  the  silver  nitrate,  or  by 
the  solid  stick,  which  can  be  used  freely  in  the  hand  of 
an  expert.  It  is,  however,  quite  unsafe,  as  a  rule,  to  en- 
trust silver  solutions  and  caustic  to  patients  themselves 
or  to  their  friends,  as  the  abuse  or  the  misuse  of  this 
valuable  agent  follows  in  a  great  percentage  of  cases. 
For  individual  use  the  milder  washes,  lotions,  and  gar- 
gles may  be  ordered,  such  as — 

^.  Potass,  chlorat,  3j ; 

Mel.  despum., 

Myrrh.,  tinct,  ad.  f3ss  ; 

Aq.  dest,  ad  fgvj. — M. 

Sig.  To  be  used,  diluted  with  water  as  required,  in  the 
throat. 

A  teaspoonful  of  this  solution  in  a  third  of  a  tumblerful 
of  pure  water  will  usually  be  found  grateful.  For  it  may 
be  substituted  1  drachm  of  the  potassic  chlorate  in  6 
ounces  of  peppermint-water,  or  a  few  drops  of  the  fol- 
lowing modification  of  Bellamy's  iodized  phenol : 
I^.  Acid,  carbolic,  3j ; 

Iodin.,  tinct.,  f^ss ; 

Glycerin., 

Spts.  vin.  rect,  dd.  f^ij ; 

Aq.  dest,  ad  f§j.— M. 

Sig.  Ten  to  fifteen  drops  in  large  dilution  as  a  mouth- 
wash and  a  gargle. 

"  Listerine,"  a  proprietary  preparation,  is  popular  with 
many  patients  (it  is  chiefly  a  weak  distillate  of  eucalyp- 


TREATMENT  OF  SYPHILIS.  257 

tus),  diluted  as  required.  .  Borolyptol,  as  containing  for- 
maline, in  the  strength  of  I  part  to  4  of  water,  an- 
swers well  as  a  mouth-wash,  a  gargle,  and  a  spray 
for  the  pharynx.  Mercurial  washes  are  also  advised, 
from  1  to  4  grains  of  the  sublimate  being  added  to 
the  half  pint  of  water,  with  tincture  of  myrrh  and  honey 
in  the  proportions  already  given.  The  objection  to 
these  washes  is  the  possibility  of  the  solution  being 
accidentally  swallowed,  and  for  that  reason  other  local 
remedies  are  to  be  preferred.  The  compressed  tablets 
containing  5  grains  each  of  the  potassic  chlorate  may 
also  be  used,  a  half  dozen  or  more,  in  case  of  need,  being 
dissolved  in  the  mouth  and  swallowed  daily.  In  all  in- 
dolent cases,  especially  where  the  drug  is  indicated  in- 
ternally, we  are  in  the  habit  of  administering  quinine, 
a  few  grains  each  day  being  laid  upon  the  tongue,  the 
local  bitter  effect  of  the  alkaloid  speedily  diffusing  itself 
through  the  mouth.  Gummatous  lesions  require  the 
use  of  the  stronger  caustics  and  call  for  the  iodide  of 
potassium  internally  in  ample  doses.  In  extreme  cases 
only  should  the  galvano-cautery  be  used.  When  the 
soft  or  the  hard  palate  is  involved,  the  medication  of 
the  patient  should  be  prompt,  as  remediless  damage  may 
be  inflicted  in  a  single  day.  The  iodide  of  potassium 
may  be  pushed  rapidly  to  the  largest  tolerated  dose,  a 
mercurial  is  usually  employed  by  inunction,  and  caustics 
are  used  freely  in  order  to  stimulate  the  engorged  tissue 
to  a  healthier  activity.  In  these  cases,  as  in  those  of  the 
milder  mucous  and  scaling  patches  of  the  mouth,  all  very 
hot,  very  cold,  acetous,  salted,  and  highly-seasoned 
articles  of  food  and  drink  should  sedulously  be  excluded 
from  the  mouth. 

Nasal  lesions  of  syphilis  require  the  internal  treatment 
indicated  in  each  particular  case,  but  the  local  manage- 
ment is  of  importance.  The  solutions  of  nitrate  of 
silver  and  the  application  of  the  crayon  itself  are  in  the 
first  rank  of  local  importance,  the  strength  of  a  solution 
and  the  severity  of  the  application  being  determined  by 

17 


258      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

the  physician  on  the  basis  of  the  grade  of  the  lesions 
present.  Local  fumigations  with  mercury,  as  already 
shown,  are  of  great  value  in  all  cases  of  severity ;  and 
unguents  of  the  yellow  oxide  or  of  ammoniated  mercury, 
I  grain  to  the  ounce  of  cold-cream  salve,  may  be  applied 
after  the  use  of  a  caustic  solution.  Douches  are  re- 
quired in  all  cases  of  ozaena ;  they  are  to  be  prepared 
with  chloride  of  sodium,  I  drachm  to  the  pint  of  distilled 
water,  one  or  more  drops  of  Bellamy's  iodized  phenol 
to  a  few  ounces  of  the  same,  or  a  weak  borated  wash. 
The  following  vapor  may  advantageously  be  snuffed 
into  the  nostrils  in  cases  of  ozaena : 

3, 


Acid,  carbolic, 

sj; 

Iodin.,  tinct., 

f3ss; 

Aq.  ammon. 

f  5ij ; 

Aq.  cologniens., 

ad  flj. 

Place  in  a  two-ounce  glass-stoppered  vial,  half  filled  with 
cotton,  and  designate  :  "  Vapor  for  snuffing  through 
the  nostrils." 

All  sequestra  of  bone  require  removal  by  accepted 
surgical  measures,  care  being  taken  lest  forcible  removal 
before  the  pieces  of  bone  are  entirely  separated  from 
their  connections  result  in  severe  shock  or,  as  has 
happened,  in  fatal  hemorrhage.  The  snare  and  the 
electro-cauteric  apparatus  may  be  needed  in  special 
cases. 

Pharyngeal  lesions  resulting  in  stenosis  or  in  adhesions 
are  to  be  treated  like  similar  sequelae  in  the  larynx — 
with  blunt  or  cutting  dilators,  the  knife,  or  the  galvano- 
cautery.  Excellent  results  may  be  obtained  in  all  mild 
cases  by  albolene  sprays  medicated  with  menthol  (1  to  2 
grains  to  the  ounce),  with  carbolic  acid,  with  pinus  Cana- 
densis, or  with  iodized  phenol  solution  (20  drops  to  the 
ounce  of  albolene).  Caustics  (nitrate  of  silver,  chromic 
acid)  are  required  for  touching  papillomatous  and  other 
growths.  In  syphilis  of  the  larynx  and  of  the  trachea 
much  eood  often  results  from  mercurial  inunction  of  the 


TREATMENT  OF  SYPHILIS.  259 

overlying  skin.  In  general,  the  iodide  of  potassium  is 
indicated  internally  ;  in  mild  cases,  however,  or  in  those 
not  threatening,  the  "  mixed  "  treatment  answers  well. 

The  nails,  when  involved  in  syphilitic  changes,  require 
special  attention.  Besides  the  constitutional  treatment 
required  in  all  cases,  the  digits  should  usually  be  pro- 
tected from  injurious  contacts  by  cots.  In  gummatous 
lesions  the  iodide  or  the  "  mixed  "  treatment  is  indicated 
internally,  and  in  non-ulcerative  forms  a  weak  mercurial 
salve  may  be  applied.  In  ulcers  of  the  soft  parts  about 
the  nail  caustic  applications  followed  by  dusting  with 
europhen  or  calomel  are  needed.  However  great  the 
apparent  deformity,  and  however  exquisitely  painful  the 
ulceration,  after  immersion  in  warm  borated  water  fol- 
lowed by  dusting-powders,  and  the  gentle  but  firm  com- 
pression of  the  parts  with  antiseptic  cotton  between 
bandage  and  ulcer,  the  dressing  may  be  made  both 
efficient  and  comfortable.  In  gouty  and  cachectic  states 
special  treatment  is  required  to  obviate  these  conditions. 

Syphilis  of  the  bones  and  the  periosteum  calls  in 
general  for  treatment  by  iodide  of  potassium,  to  relieve 
the  osteocopic  pains  and  tumefaction,  while  mercury  is 
needed  to  ensure  against  trouble  in  the  future.  In  many 
of  these  cases  the  "  mixed "  treatment  answers  well. 
Externally,  when  the  osseous  tissue  involved  is  within 
the  reach  of  such  treatment,  mercury  is  of  the  highest 
value,  unguents  and  oleates  of  mercury  being  chiefly 
employed.  Mercurial  plaster  is  often  serviceable  when 
cut  to  the  proper  shape  and  more  or  less  continuously 
worn  over  any  accessible  nodes  or  tumors.  It  is  rarely, 
if  ever,  necessary  to  incise  local  gummatous  deposits ; 
and  any  sequestra  formed  as  a  result  of  syphilitic  caries 
or  necrosis  should  be  removed  surgically  only  when 
completely  separated.  The  familiar  surgical  procedure 
of  making  long  incisions  the  length  of  a  bony  "  splint  " 
along  the  tibia  is,  in  syphilitic  cases,  for  the  most  part 
wholly  unnecessary  and  without  value.  Surgical  interfer- 
ence is  on  rare  occasions  required  when  there  is  pressure 


26o      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

upon  a  nerve-trunk  by  an  osseous  or  osteo-periosteal 
tumor.  All  abscesses  require  proper  surgical  opening- 
and  drainage.  Separation  of  an  epiphysis  demands  cor- 
rection of  any  resulting  deformity,  and  immobilization 
of  the  limb  by  the  aid  of  a  splint. 

Plastic  operations  are  often  of  decided  value  in  cor- 
recting the  most  hideous  of  the  facial  deformities  pro- 
duced by  bone-syphilis  ;  and  in  grave  cases  an  artificial 
nose  may  be  worn.  Sinking  of  the  nasal  bridge  is  well 
corrected  by  platinum  and  other  supports.  In  dactylitis 
syphilitica  amputation  should  almost  never  be  practised. 
Great  relief  can  be  obtained  by  medical  treatment  (iodide 
of  potassium  internally),  by  mercurial  frictions  where 
there  is  no  degeneration  of  tissue,  by  incision  of  all 
suppurating  tissue  (in  lines  parallel  with  the  long  axis  of 
the  limb  in  the  effort  to  avoid  wounding  tendons),  and 
by  strict  observance  of  antiseptic  precautions. 

The  viscera,  when  the  seat  of  the  lesions  of  syphilis, 
require,  for  the  most  part,  internal  treatment,  which  is 
to  be  pursued  according  to  the  indications  in  each 
case.  It  has  already  been  noticed  that  the  suggestion 
that  syphilis  is  a  possible  cause  of  aneurysm  was  origi- 
nally due  to  the  recognized  value  of  iodide  of  potassium 
in  that  affection.  In  syphilis  of  the  heart,  lungs,  liver, 
kidney,  and  spleen  the  iodide  of  potassium,  occasionally 
in  combination  with  mercury,  is  indicated,  and  in  many 
cases  is  of  great  service.  In  other  cases,  especially  when 
degeneration  of  cells  has  been  wrought,  the  treatment, 
while  not  always  curative  in  its  results,  exhibits  a  marked 
power  in  arrest  of  the  malady.  In  all  cases  of  visceral 
syphilis,  however,  there  is  urgent  need  of  systemic  treat- 
ment beyond  that  which  might  strictly  be  called  "  anti- 
syphilitic,"  patients  being  often  in  a  cachectic  or  anaemic 
state.  Special  complications  also  arise  (ascites,  albumin- 
uria, cough,  haemoptysis,  jaundice,  etc.),  requiring  the 
particular  treatment  recognized  in  general  medicine  as 
appropriate  to  each. 

Syphilitic  lesions  of  the  rectum  and  the  anus  always 


TREATMENT  OF  SYPHILIS.  26 1 

demand  special  attention.  By  the  aid  of  nitrate  of  silver 
in  solution  (from  5  to  10  grains  to  the  ounce)  all  fissures 
of  the  anal  folds  may  be  stimulated,  and  they  may  be 
dressed  subsequently  with  iodol  or  europhen  powders 
with  superimposed  lint.  Before  each  stool,  the  rectum, 
as  far  as  can  readily  be  reached  with  the  finger,  is  to  be 
well  smeared  with  the  following : 

1^.  Benzoin.,  tinct,  f^j ; 

Unguent,  aq.  ros., 
Vaselin.,  da.  5ss. — M. 

Sig.  For  external  application  with  the  finger  as  directed. 

Enemata  of  warm  water  must  be  ordered  if  the  bowels 
are  impacted. 

All  gummatous  lesions  call  for  iodide  of  potassium  in 
the  largest  doses  required  to  secure  involution,  mercury 
being  at  the  same  time  carefully  and  judiciously  em- 
ployed. Strictures  of  the  rectum  are  to  be  treated 
at  first  with  dilatation  by  rubber  bougies,  care  being 
taken  not  to  rupture  the  gut  and  induce  a  peritonitis. 
When,  as  is  too  often  the  case,  the  result  is  a  mere 
temporary  benefit,  the  last  resorts  are  posterior  proc- 
totomy, division  of  stricture  by  the  galvano-cautery, 
inguinal  colotomy,  and  complete  excision  of  the 
neoplasm,  as  in  case  of  carcinoma.  In  emergencies  re- 
quiring surgical  interference  we  have  found  inguinal 
colotomy  most  serviceable.  In  a  few  instances,  after 
the  irritation  produced  by  the  passage  of  faeces  over  the 
rectum  has  been  removed,  the  latter  organ  has  under 
treatment  returned  to  a  condition  permitting  of  closure 
of  the  artificial  anus  in  the  groin.  As  most  of  the 
subjects  of  this  disorder  are  women,  the  pain  attending 
subsequent  menstruation  often  requires  attention. 

Syphilitic  lesions  of  the  epididymis  and  body  of  the 
testicle  are  usually  amenable  to  treatment  with  iodide  of 
potassium  internally  and  mercury  externally,  the  latter 
employed  in  the  form  of  either  the  oleate  or  the  oint- 
ment.   Many  of  these  cases  call  for  prompt  and  energetic 


262      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

treatment  to  avert  aspermatism,  which  too  often  ensues 
even  if  atrophy  does  not  follow  absorption  of  the  gum- 
matous mass.  An  accompanying  hydrocele  usually  re- 
quires tapping.  Even  after  implication  of  both  testes 
it  is  often  difficult  to  persuade  patients  of  the  need  of 
absolute  disuse  of  the  sexual  organs. 

Lesions  of  the  nervous  system,  whether  of  the  brain, 
the  meninges,  or  the  cord,  usually  require  internal  treat- 
ment of  similar  character  in  each  complication.  It  has 
been  customary  to  employ  in  these  cases  the  largest 
tolerated  doses  of  iodide  of  sodium  or  iodide  of  potas- 
sium ;  and  the  result  in  favorable  cases  is  as  brilliant  as 
it  is  satisfactory.  One  of  these  salts,  or  both  in  combina- 
tion, may  be  administered  in  a  saturated  solution  in  drop 
doses,  the  vehicle  being  milk,  alkaline  water,  or  an  es- 
sence of  pepsin  taken  before  or  after  meals,  with  another 
dose  at  bed-time.  In  all  emergency  cases  it  is  well  to 
disregard  the  hours  of  meals,  and  to  administer  the 
remedy  every  four  hours  during  the  wakeful  periods  of 
the  day  and  night.  By  the  addition  of  1  or  2  drops  of 
a  saturated  solution  either  to  each  or  to  each  third  or 
fourth  dose,  very  large  quantities  of  iodide  of  potassium 
have  been  taken  with  favorable  results,  an  ounce  and 
even  two  ounces  and  more  having  been  thus  ingested 
within  twenty-four  hours.  For  the  caution  requisite  in 
the  attainment  of  and  persistence  in  these  large  doses 
the  reader  is  referred  to  preceding  pages  devoted  to  the 
subject  of  the  employment  of  the  iodides. 

Inunctions  of  mercury  at  the  same  time  with  the 
medication  may  generally  be  practised  with  the  best 
results  ;  while  the  "  mixed  "  treatment  is  to  be  reserved 
for  cases  exhibiting  no  signals  of  danger  and  calling  for 
no  specially  energetic  management. 

The  belief,  however,  is  now  gaining  ground  that  too 
much  stress  has  in  the  past  been  laid  upon  the  treatment 
of  nervous  syphilis  with  the  iodine  salts,  and  that  the 
great  value  of  mercury  has  needlessly  been  ignored  in 
these  grave  complications  of  the  disease.     We  are  in  the 


TREATMENT  OF  SYPHILIS.  263 

habit,  in  all  severe  cases,  of  carefully  testing  the  condi- 
tion of  the  patient  by  giving  ^  grain  of  calomel,  or  even 
more,  every  hour  until  a  decided  effect  has  been  pro- 
duced ;  and  certainly  the  gravest  types  of  pachymen- 
ingitis have  thus  been  relieved.  Tonics  are  demanded 
in  all  cases  of  nervous  syphilis  where  the  crisis  of  the 
disease  has  been  combated  successfully,  and  often  before 
such  an  event.  The  diet  should  be  in  a  high  degree 
nutritious,  the  feet  are  to  be  kept  warm,  and  tobacco  and 
alcohol  are  rigidly  to  be  excluded.  For  the  majority  of 
patients  we  are  opposed  to  the  employment  of  hot  baths 
in  nervous  syphilis,  preferring,  in  general,  the  daily 
sponging  of  the  body-surface  with  a  strong  solution  of 
salt  and  water  followed  by  frictions  with  the  flesh-brush. 
Fumigations  also,  valuable  though  they  may  be  in  other 
syphilitic  states,  are,  equally  with  the  hot  bath,  to  be 
avoided,  as  in  various  degrees  are  apt  to  induce  congestion 
of  the  nervous  centres.  In  syphilitic  patients  convulsive 
seizures  of  a  severe  grade  have  been  precipitated  both  in 
the  fumigation  chamber  and  in  Turkish  and  Russian 
baths. 

Syphilis  of  the  eye  and  its  appendages  is  to  be  treated 
internally  on  the  principles  already  formulated.  Mild 
astringent  lotions  locally  answer  well  for  most  of  the 
simpler  inflammations  of  the  canaliculi  and  the  sac ;  in 
rare  cases  only  is  division  for  stricture  or  the  introduc- 
tion of  the  probang  required.  When  the  sclerotic  is  in- 
volved, instillations  of  atropia,  combined,  if  there  be  pain, 
with  cocaine,  are  useful.  In  iritis  of  all  forms  repeated 
applications  of  hot  water  slightly  impregnated  with  boric 
acid  are  to  be  made  over  the  closed  lids,  and  solutions 
of  atropia  (from  1  to  4  grains  to  the  ounce)  instilled 
sufficiently  often  to  ensure  persistent  dilatation  of  the 
pupil  and  to  tear  loose  any  adhesions  between  the  iris 
and  the  capsular  envelope  of  the  lens.  Persistence  in 
these  efforts  is  rewarded  with  success  in  cases  which 
often  look  desperate,  when  blood  is  effused  into  the 
anterior  chamber,  and  there   are  apparently  unyielding 


264      SYPHILIS   AND    THE   VENEREAL   DISEASES. 

attachments  of  the  free  border  of  the  iris.  Opium  for 
relief  of  pain  is  rarely  required  in  well-managed  cases, 
and  is  contraindicated  by  the  effect  of  the  drug  on  the 
pupil ;  hence,  if  it  be  used  in  an  emergency,  the  atropia 
must  be  employed  in  doses  sufficient  to  counteract  fully 
the  pupillary  action  of  the  narcotic.  Leeches  may  be 
ordered  to  the  temple  in  plethoric  subjects  or  in  case  of 
emergency.  Mercury  is,  as  a  rule,  best  employed  by 
inunction,  and  the  iodide  by  the  mouth. 

Seclusion  of  the  affected  eye  from  the  light  must  be 
secured,  and  must  be  continued  for  some  time  after  relief 
is  obtained,  in  order  to  avoid  recurrence,  which  is  not 
rare.  Posterior  synechiae,  as  liable  to  result  eventually 
in  glaucoma,  call  for  operative  interference  only  when 
persistent.  Iridectomy  is  a  last  resort  in  cases  which 
by  good  management  should  have  had  a  more  favorable 
issue.  In  all  affections  of  the  choroid  the  ciliary  muscle 
should  be  paralyzed  with  atropia,  and  when  the  optic 
nerve  is  involved  strychnia  is  indicated.  In  all  bony 
affections  of  the  orbit  the  iodide  is  to  be  pushed  to  the 
fullest  doses  tolerable,  as  in  gummatous  lesions  of  the 
liver,  brain,  and  testis. 

Syphilitic  lesions  of  the  external  ear  demand  semi- 
liquid  unguents  containing  mercury,  carbolic  acid,  or 
boric  acid,  applied  by  means  of  a  toothpick  wrapped  in 
cotton  or  on  pledgets  of  lint.  Weak  mercuric  oleate  (5 
per  cent.)  mixed  with  oil  of  benne  may  also  be  applied. 
In  the  interest  of  antisepis,  the  meatus  should  be  cleansed 
daily  with  warm  borated  douches  ;  vegetations  should  be 
snipped  away  with  fine  scissors,  and  their  bases  cauterized 
with  the  nitrate  of  silver,  care  being  taken  to  avoid  the 
drum.  Too  violent  treatment  is  likely  to  occlude  the 
canal  by  a  consequent  swelling.  When  this  swelling 
occurs,  the  walls  are  to  be  prevented  from  adhesion  by 
the  interposition  of  pledgets  of  lint.  Warm  sublimate 
lotions,  1  :  10,000,  are  also  valuable  when  operative  treat- 
ment is  not  demanded. 

In  syphilis  of  the  tympanum  the  naso-pharynx  always 


TREATMENT  OF  SYPHILIS.  265 

requires  attention.  Inflation  of  the  Eustachian  tube  with 
iodinized  vapor  is  in  this  region  distinctly  beneficial. 
The  constitutional  management  is  of  importance,  and 
especially  the  care  of  the  feet,  which  should  be  kept  dry 
and  warm  and  be  dusted  nightly  with  either  salicylic 
or  boric  acid.  Suppuration  of  the  middle  ear  is  a  grave 
complication  which  may  terminate  fatally ;  for  details  of 
its  strictly  antiseptic  management  the  reader  is  referred 
to  special  text-books  on  aural  disease.  Syphilitic  involve- 
ment of  the  labyrinth  can  be  treated  only  by  internal 
medication. 

Hereditary  Syphilis. — A  woman  known  to  be  syphi- 
litic and  pregnant  should  have  prompt  and  energetic 
antisyphilitic  treatment,  in  the  interest  not  only  of  her- 
self but  also  of  her  unborn  child.  Genital  lesions  require 
frequent  and  careful  applications  with  a  view  to  asepsis. 
Warm  borated  lotions,  or  solutions  of  the  permanganate 
of  potassium,  1  grain  to  2  ounces,  should  be  used — with 
caution,  however,  when  employed  as  vaginal  lotions, 
since  a  stream  of  warm  water  directed  against  the  cervix 
of  a  pregnant  uterus  has  brought  on  labor. 

The  special  treatment  of  the  pregnant  woman  is  by 
mercurial  inunctions  pushed  within  the  limits  of  a 
decided  effect  upon  the  gums,  and  suspended  for  periods 
during  which  she  is  to  be  subjected  to  "  mixed  "  treat- 
ment. The  mercuric  protoiodide,  blue  pill,  and  other 
pilular  vehicles  of  the  metal  are  less  serviceable  than 
the  method  named.  In  advanced  syphilis  the  iodide  in 
full  doses  is  of  unquestioned  value  and  has  saved  the 
lives  of  many  children. 

In  the  management  of  the  syphilitic  infant  at  the 
breast  the  mercurial  and  other  treatment  of  the  mother 
is  not  to  be  neglected.  Whether  the  very  small  amount 
of  mercury  detected  in  the  milk  is  of  value,  or  whether 
the  improvement  which  has  been  noted  on  the  part  of 
the  child  is  due  to  the  enrichment  of  the  quality  of  the 
milk  of  the  mother  whose  health  is  benefited  by  the 
treatment,  it  is  not  necessary  to  determine.     In  admin- 


266      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

istering  iodide  of  potassium  to  a  nursing  mother  it  should 
be  remembered  that  at  times  the  remedy  has  a  very- 
decided  influence  in  inducing  suppression  of  the  milk — 
an  accident  of  serious  import  when  a  syphilitic  child  is 
at  the  breast. 

The  direct  treatment  of  the  syphilitic  infant  is  a  matter 
of  the  greatest  moment.  Only  upon  very  strong  evi- 
dence should  treatment  of  a  syphilitic  infant  be  begun 
before  it  has  betrayed  symptoms  of  inherited  disease, 
since,  even  after  the  birth  of  "  intensely "  syphilitic 
foetuses  and  a  series  of  abortions,  there  are  brought  into 
the  world  children  who  never  exhibit  signs  of  the  disease 
even  when  both  parents  have  recently  been  infected. 
This  note  of  warning  should  be  heeded,  as  some  physi- 
cians are  ready  to  pronounce  a  sickly  child  syphilitic 
simply  because  they  have  knowledge  of  the  venereal 
accidents  of  one  or  both  parents  occurring  a  brief  time 
before  pregnancy. 

Seeing  that  a  syphilitic  infant  does  not  infect  the  breast 
of  its  mother,  the  child  should  always,  when  practi- 
cable, be  thus  nourished,  and  should  never  be  suffered 
to  take  the  breast  of  a  sound  woman.  If  breast-milk 
cannot  be  had,  goat's  milk  may  be  employed  as  a  sub- 
stitute, or  sterilized  cow's  milk,  or  cream  and  warm 
water.  A  healthy  wet-nurse  should  at  all  hazards  be 
prevented  by  the  physician  from  exposing  herself  to  the 
dangers  of  infection.  A  syphilitic  wet-nurse  is  unfit  for 
service.  Where  the  utmost  care  is  requisite  in  the 
cleanliness  of  the  mouth,  nose,  anus,  vulva,  umbilicus, 
etc.,  the  woman  who  is  herself  suffering  from  the  acci- 
dents of  infection  is  liable  to  be  a  carrier,  not  of  a  new 
syphilis,  but  of  the  germs  of  a  secondary  infection  from 
pyogenic  cocci. 

When  exhibiting  snuffles  and  the  exanthemata  of 
hereditary  disease,  the  child  may  be  given  internally 
calomel  rubbed  up  with  sugar  of  milk — from  ^  to  -^ 
grain  to  the  weak ;  to  those  who  are  stronger,  from  \  to 
\  grain  three  times  in  the  day.      The  crushed  tablet- 


TREATMENT  OF  SYPHILIS.  267 

triturates  of  this  salt  administered  in  milk  serve  a  useful 
purpose.  An  accompanying  opiate  to  relieve  diarrhoea, 
advised  by  some  authors,  is  rarely  needed  if  the  dosage 
be  adjusted  accurately  to  the  requirements  of  each  case. 
Tonics  are  as  necessary  for  the  infant  as  for  the  adult 
affected  with  syphilis.  A  few  drops  of  a  solution  of 
citrate  of  iron  and  quinine,  a  drachm  to  the  ounce,  may 
be  given  in  syrup  ;  or  Monti's  formula : 

fy.  Ferri  lact,  gr.  v ; 

Hydrarg.  chlor.  mit,  gr.  iss  ; 

Sacch.  lactis,  gr.  xxx. — M. 

Ft.  chart.  No.  x. 
Sig.  One  to.be  given  after  taking  the  breast. 

The  gray  powder,  once  highly  commended,  is  un- 
certain, in  consequence  of  its  liability  to  the  production 
of  the  bichloride  of  mercury.  It  is  given  in  doses  of 
from  yo  to  I  grain,  according  to  the  weight  of  the  child. 
We  believe  these  preparations  to  be  preferable  to  the 
others  named  below,  which  should,  on  the  whole,  be 
reserved  for  cases  where  there  is  decided  intractability 
under  the  dosage  of  the  mild  chloride  or  the  gray 
powder.  But  the  protoiodide  is  given  in  combination 
with  lactate  of  iron  in  doses  of  from  ^  to  \  grain  rubbed 
up  with  the  sugar  of  milk  ;  black  oxide  of  mercury,  in 
doses  of  a  similar  size;  and  corrosive  sublimate,  in  doses 
of  from  ^  to  ^  grain. 

Iodide  of  potassium  in  solution  may  be  administered 
to  young  children  in  doses  of  from  J  grain  to  4  grains. 
This  remedy,  however,  in  infants  and  children  is  exceed- 
ingly liable  to  produce  a  severe  grade  of  medicamentous 
dermatitis  and  the  other  accidents  of  iodism  ;  further- 
more, it  is  not  so  often  as  in  adults  productive  of  bril- 
liant therapeutic  effects.  It  is  chiefly  indicated  when 
there  are  osseous  lesions  and  those  involving  the  brain, 
the  viscera,  the  testes,  the  eye,  and  the  ear.  The  mixed 
treatment  advised  for  adults  can  often  be  used,  however, 


268      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

with  advantage  in  cases  where  no  emergency  exists,  as, 
for  example : 

ly.  Hydrarg.  biniodid.,  gr.  j  ; 

Potass,  iodid.,  3iij  ; 

Syr.  simpl., 

Aq.  menth.  piperit.,      da.  f  siss. — M. 
Sig.  From  3  to  10  drops  to  be  swallowed  in  large  dilu- 
tion, after  taking  food,  three  times  a  day. 

Mercurial  inunctions,  advised  by  some  authors  only 
after  the  child  has  attained  a  certain  age  and  degree  of 
strength,  we  employ  with  great  advantage  as  soon  as 
indicated  in  the  earliest  periods  of  life.  It  is  not  the 
method,  but  the  skill  directing  the  method,  that  renders 
this  procedure  possible.  In  very  young  infants  the  skin 
is  exquisitely  sensitive  and  unable  to  endure  mercurial 
frictions.  In  such  cases  the  mercurial  ointment  is  com- 
bined with  1,  2,  or  more  parts  of  pure  white  vaseline, 
and  the  swathing  band  is  well  anointed  with  the  mixture, 
care  being  observed  that  the  bandage  be  fastened  so  that 
it  does  not  turn,  and  also  that  one  part  of  it  only  be 
anointed.  In  this  way  the  constant  motions  of  the  child 
produce  a  gentle  inunction,  which  may  be  pushed  to  any 
desired  extent  by  increasing  the  quantity  of  the  mer- 
curial in  the  unguent  until  a  scruple  or  more  is  rubbed 
in  daily.  During  all  these  applications  the  child  should 
be  watched  carefully,  and  on  the  slightest  evidence  of 
debility,  anaemia,  or  increased  restlessness  the  remedy 
should  be  suspended.  The  same  course  should  be 
pursued  when  it  is  observed  that  the  skin  over  which 
the  ointment  has  been  applied  is  the  seat  of  a  mild  der- 
matitis ;  in  which  event,  if  the  general  condition  warrant, 
the  inunctions  may  be  practised  over  another  region, 
as  over  the  feet  or  the  shoulders.  In  point  of  fact,  a 
syphilitic  infant  furnishes  a  ready  and  constant  indication 
of  the  value  of  the  treatment  instituted  for  its  relief,  in- 
asmuch as  its  increase  in  weight,  its  improvement  in 
color,    and    its    capacity    for    eating   and    sleeping    are 


TREATMENT  OF  SYPHILIS.  269 

promptly  changed  for  the  better  or  the  worse  according 
as  such  treatment  is  or  is  not  rightly  directed.  In  the 
event  of  irritation  of  the  skin  being  produced  in  any 
region  where  a  mercurial  has  been  applied,  the  inunc- 
tions should  at  once  be  suspended  and  the  integument 
of  that  part  dusted  with  a  soothing  powder  such  as  talc 
or  starch,  or,  in  case  of  need,  anointed  with  freshly  made 
benzoinated  zinc  ointment. 

What  good  can  be  wrought  by  inunction  is  within 
the  range  of  either  mercurial  ointment,  pure  or  reduced, 
or  the  several  mercuric  oleates.  The  red  precipitate  in 
the  strength  of  a  I  per  cent,  ointment,  the  white  pre- 
cipitate in  the  strength  of  1  part  to  10  of  lanolin  or 
vaseline,  and  mercurial  plaster  for  regions  of  limited  area, 
have  all  been  praised  by  authors,  and  may  be  regarded 
as  of  value  when  a  change  is  thought  desirable.  Hypo- 
dermatic injections  and  fumigations  have  been  employed 
in  hereditary  as  in  acquired  syphilis,  but  no  urgent 
reason  for  their  use  can  be  adduced.  In  the  event  of 
their  selection,  the  dose  should  be  reduced  somewhat 
from  that  employed  in  adults,  according  to  the  age  of 
the  child.  From  -^  to  -^  grain  of  the  sublimate  can  be 
injected  between  the  first  and  fourth  years,  the  smaller 
doses  only  in  the  first  twelvemonth  of  life.  The  subli- 
mate baths  recommended  by  Elsenberg  contain  about  a 
grain  of  the  metal,  an  equal  quantity  of  the  ammonium 
chloride  being  added,  to  the  gallon  of  warm  water.  The 
local  applications  found  useful  in  acquired  syphilis  may 
be  employed  when  needed  in  the  case  of  syphilitic  infants. 
The  addition  of  ammoniated  mercury,  calomel,  or  yellow 
oxide  to  the  Lassar  paste  already  described,  in  the 
strength  of  from  2  to  30  grains  to  the  ounce,  will  be 
found  available  in  many  of  the  syphilodermata.  Tumors 
and  nodes  should  rarely  be  opened  surgically,  as  they 
can  commonly  be  made  to  disappear  under  an  appro- 
priate therapy.  When  the  lids  are  affected,  warm  borated 
lotions,  or  those  containing  the  bichloride,  I  part  in 
10,000,  may  be  employed,  followed  by  a  weak  salve  con- 


27O      SYPHILIS  AXD    THE   VENEREAL   DISEASES. 

taining  a  grain  of  the  yellow  oxide  of  mercury.  Atro- 
pine should  be  instilled,  as  often  as  required,  both  in 
keratitis  and  in  iritis,  in  the  strength  of  from  T\j  to  \ 
grain  to  the  ounce.  Leeches  may  be  required  over  the 
mastoid  process  to  relieve  the  severe  deafness  of  inherited 
disease,  which,  if  not  energetically  treated,  may  result 
in  deaf-mutism.  No  applications  are  better  for  the 
special  rhinitis  of  hereditary  syphilis  than  those  contain- 
ing nitrate  of  silver,  from  \  to  I  grain  to  the  ounce 
being  injected  or  wiped  over  the  surface,  and  followed 
by  an  albolene  spray.  In  some  cases  this  spray  answers 
well,  employed  alone  or  after  the  addition  to  it  of  a  few 
drops  of  carbolic  acid  and  a  single  drop  each  of  the 
tincture  of  iodine  and  glycerin.  The  mouth  should  be 
cleansed  thoroughly  and  repeatedly  with  solutions  of 
boric  acid  and  honey,  usually  best  applied  by  dipping  in 
the  solution  a  soft  rag  or  a  handkerchief  which  is  wound 
about  the  finger  of  the  nurse  and  then  applied  to  every 
part  of  the  child's  mouth.  The  anus  should  be  kept 
scrupulously  clean,  and  should  frequently  be  dusted  with 
boric  acid  or  boric  acid  and  talc  in  equal  parts ;  if 
condylomata  form,  these  should  be  deodorized  with 
liquor  sodae  chlorinatse,  and  after  drying  should  be 
dusted  with  calomel  and  talc,  1  part  of  the  former  to  4 
parts  of  the  latter.  Mercurial  plasters  are  useful  appli- 
cations to  tumors  and  swellings  over  bone,  digit,  joint, 
or  muscle,  and  can  also  be  wrapped  neatly  about  an 
involved  testis. 

Acquired  Infantile  Syphilis. 

The  acquired  syphilis  of  infants  differs  from  the  in- 
herited form  chiefly  in  the  important  particulars  that  its 
evolution  is  on  the  lines  observed  by  the  acquired 
disease,  and  that  the  patient  does  not  start  life  with 
lesions  of  the  viscera,  of  the  bones,  or  of  other  important 
organs.  As  a  rule,  under  proper  care  the  issue  in  these 
cases  is  fairly  favorable.  The  acquired  syphilis  of  infancy 
is  chiefly  remarkable  for  its  display  of  moist  and  secret- 


SYPHILIS  AND    THE   FAMILY.  2JI 

ing  lesions  and  for  its  failure  to  relapse  in  cycles  as  does 
acquired  disease  of  adults.  The  first-named  feature  is 
due  to  the  soft  character  of  the  infant's  tissues ;  the  last- 
named,  to  the  constant  control  to  which  the  child  is 
subjected  when  the  disease  is  duly  recognized  and  prop- 
erly cared  for.  But  in  unrecognized  or  neglected 
acquired  syphilis  of  infancy  the  results  may  be  as  mu- 
tilating and  as  disfiguring  as  in  the  worst  phases  of 
acquired  disease  of  later  years. 


SYPHILIS    IN    RELATION   WITH    THE    FAMILY 
AND    SOCIETY. 

It  is  obvious  that  if  every  infected  individual  were 
restrained  from  communicating  syphilis  to  another,  the 
extension  of  the  disease  would  speedily  be  checked. 
Unfortunately,  the  barriers  to  such  an  advance  in  the 
improvement  of  the  public  health  seem  at  present  to  be 
insuperable.  The  duty  of  the  physician,  however,  is 
none  the  less  clear  and  urgent.  The  victim  of  the 
disease  should  be  impressed  with  the  fact  that  he  is  a 
possible  source  of  danger  for  the  uninfected,  and  should 
be  shown  the  methods  by  which  he  is  to  protect  those 
with  whom  he  must  necessarily  come  in  contact.  To 
the  father  of  a  family  and  to  the  unmarried  of  both 
sexes  it  is,  in  general,  proper  to  state  the  nature  of  the 
disease  recognized,  if  this  be  unknown  before  the  date 
of  consultation,  and  also  to  point  out  the  danger  of 
transmission  and  the  methods  by  which  such  accident 
may  be  prevented.  In  the  presence  of  a  syphilitic  wife 
ignorant  of  her  condition  the  physician  is  placed  in  a 
position  of  peculiar  delicacy.  As  a  rule,  these  innocent 
victims  of  the  disease  have  been  infected  by  a  guilty 
husband.  The  physician  then  discharges  his  task  if  he 
insists  upon  a  personal  interview  with  the  master  of  the 
household,  declaring  the  facts  to  the  latter  and  insisting 
upon  the  need  of  informing  his  partner  at  once  of  the 


272      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

nature  of  the  disorder,  that  she  may  take  such  measures 
as  will  ensure  her  safety.  In  such  cases  it  is  plainly  the 
office  of  the  husband  rather  than  of  the  physician  to 
perform  this  disagreeable  duty.  An  infected  wife  sep- 
arated from  her  husband  by  death,  divorce,  or  mutual 
arrangement  should,  as  a  rule,  learn  the  truth  directly 
from  her  physician.  It  is  her  right  to  understand  the 
nature  of  her  disorder,  that  in  any  emergency  she  may 
have  a  clue  to  the  treatment  which  may  then  be  de- 
manded urgently.  Women  have  actually  lost  their  lives 
in  consequence  of  ignorance  on  this  point.  Before,  how- 
ever, any  communications  of  this  sort  are  made  by  the 
physician  to  the  patient,  the  former  should  be  absolutely 
certain  of  the  correctness  of  the  diagnosis.  As  the 
peace  of  a  family  is  often  at  stake,  an  error  here  is 
unpardonable.  In  any  case  of  doubt  further  advice 
should  be  sought. 

If  the  husband  or  the  wife  be  infected  from  an  extra- 
marital source,  it  is  the  obvious  duty  of  the  diseased  to 
inform  the  sound  partner  of  the  fact,  that  he  or  she  may 
take  precautions  sufficient  to  ensure  safety.  Here,  too, 
it  is  plainly  the  duty  of  the  guilty  to  inform  the  innocent, 
and  the  physician  has  a  right  to  insist  upon  the  perform- 
ance of  this  duty,  to  save  not  merely  the  uninfected,  but 
also  his  own  personal  reputation.  Otherwise,  when  the 
facts  are  eventually  discovered  (and  they  usually  are)  he 
may  be  held  to  have  been  a  party  to  a  plot  to  conceal 
the  truth  to  the  damage  of  the  infected.  If  there  be  a 
positive  refusal  of  the  patient  to  discharge  this  duty, 
there  are  two  ways  in  which  the  physician  may  proceed : 
One  is  that  suggested  by  Fournier :  The  physician  may 
send  a  written  letter  to  the  guilty  party,  insisting  upon 
the  need  of  telling  the  truth,  and  retain  a  copy  of 
this  letter  for  later  justification.  The  other  way  is 
for  the  physician  to  decline  further  connection  with  the 
case. 

As  a  matter  of  fact,  in  the  great  majority  of  all  cases 
the   infected   consort    cohabitine  with    the    non-infected 


SYPHILIS  AND    THE   FAMILY.  273 

person  who  is  ignorant  of  the  facts  sooner  or  later  trans- 
mits the  disease,  notwithstanding  all  protestations  and 
precautions.  As  a  matter  of  fact  also,  the  "  confessed  " 
cases  are  those  where  transmission  almost  never  occurs. 
There  is  sufficient  popular  dread  of  the  disease  to  ensure 
the  forewarned  against  the  incurrence  of  risk.  Excep- 
tions may  possibly  be  made  in  the  instance  of  long 
separation  of  husband  and  wife,  or  of  long-continued 
illness  of  either,  rendering  the  performance  of  the  sexual 
act  impossible  or  remotely  improbable  ;  and  also  in  cases 
where  each  of  the  married  couple  habitually  occupies  a 
separate  chamber  and  bed.  In  some  of  these  cases  the 
temptation  to  indulge  in  the  sexual  act,  from  a  sudden 
and  scarcely  resisted  impulse,  at  a  time  when  objective 
symptoms  of  the  malady  seem  to  be  for  the  moment  re- 
moved, is  to  a  large  extent  set  aside. 

It  is  a  remarkable  evidence  of  the  tenacity  with  which 
the  marriage  tie  unites  even  those  who  have  disregarded 
its  sacredness,  that  but  a  small  proportion  of  the  men 
who  confess  to  their  wives  their  fall  and  their  infection 
by  that  fact  alone  break  up  their  families.  It  is  an 
offence  against  a  woman,  usually  unpardoned,  if  her 
husband,  after  violating  his  marriage  vow,  afterward  in- 
flicts upon  her  a  venereal  disorder  through  a  cowardly 
dread  of  confessing  the  truth.  The  courts  fully  recog- 
nize this,  and  give  her,  when  she  asks  it,  speedy  and 
just  redress.  In  daily  practice,  however,  a  man  who, 
unfaithful  to  his  wife,  has  been,  as  a  consequence,  in- 
fected, and  who  confesses  to  her  his  story  rather  than 
contaminate  her  in  his  embrace,  usually  wins  her  sym- 
pathy and  often  retains  her  love.  She  respects  his 
courage,  and  if,  as  often  proves  to  be  the  case,  the  hus- 
band has  committed  his  offence  when  under  the  influence 
of  alcoholic  stimulants,  she  often  forgives.  The  con- 
scientious physician  cannot  be  too  strongly  urged  to 
conserve  the  health  and  the  peace  of  families  threatened 
by  the  advent  of  an  infectious  disease  by  exerting  all  his 
influence  in  the  direction  of  securing  a  confession  to  the 

18 


274      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

wife  by  the  husband,  who  in  the  great  majority  of  all 
cases  is  the  one  at  fault. 

It  need  not  here  be  set  down  that  the  unmarried  in- 
fected with  syphilis  should  not  indulge  in  the  sexual  act. 
When  under  an  engagement  to  marry  at  the  date  of  in- 
fection, both  parties  to  the  contract  should  earnestly  be 
advised  to  cancel  the  engagement.  In  the  intimacy 
between  two  such  persons  made  possible  in  most  classes 
of  society,  a  kiss  upon  the  lips  has  often  served  to  trans- 
mit the  disease,  and  to  convert  an  affectionate  regard 
into  a  feeling  of  detestation  and  horror.  For  most  of 
these  people  a  period  of  three  years  at  the  least  is  likely 
to  elapse  before  the  physician  can  consent  to  a  union, 
and  it  is  unjust  to  expect  a  young  woman  to  bind  her- 
self for  that  period  to  any  man  capable  of  acquiring 
syphilis  by  the  usual  methods  of  its  transmission.  The 
course  which  will  in  the  end  save  the  most  mental  and 
physical  misery  for  both  persons,  and  which  will  in  the 
future  furnish  the  least  anxiety  to  the  physician,  is  dis- 
ruption of  the  bond. 

With  respect  to  the  marriage  of  the  veteran  of  syphilis 
the  decision  may  be  different.  There  is  no  time  in  the 
life  of  the  infected  when,  for  any  reasons  known  to 
science,  it  may  positively  be  affirmed,  without  possi- 
bility of  disproof,  that  he  or  she  can  become  the  pro- 
genitor of  healthy  children  and  not  infect  a  partner  in 
marriage.  This  is,  in  effect,  a  proposition  that  the  in- 
fected should  never  marry ;  and,  as  thousands  of  men 
annually  do  marry  and  have  sound  children  and  never 
transmit  syphilis  to  their  wives,  it  follows  that  there  must 
be  some  rule  which,  if  not  absolutely  safe,  will  furnish 
in  its  application  a  maximum  of  practical  and  satisfactory 
results. 

It  is  wholly  unfair,  when  considering  the  question  of 
marriage  from  the  point  of  view  of  medical  science,  to 
set  the  patient  who  has  made  a  satisfactory  progress  to- 
ward the  termination  of  syphilis  in  a  category  apart  from 
the  tuberculous,  from  those  having  a  record  of  recur- 


SYPHILIS  AND    THE   FAMILY.  2J%, 

ring  insanity  in  their  family  histories,  and  from  those 
affected  with  infirmities  tolerably  certain  to  terminate 
life  within  a  brief  period  of  time.  All  these  classes 
annually  marry  and  intermarry,  with  disastrous  results 
to  themselves  and  to  society.  The  veterans  of  syphilis 
make  a  far  better  statistical  showing. 

It  is  impossible  to  lay  down  rules  for  all  cases,  but  the 
following  limits  are  fairly  well  established  in  practice : 
A  previously  healthy  young  man  or  woman,  skilfully 
treated  for  between  three  and  four  years  after  infection, 
and  free  for  the  last  year  from  any  but  the  most  insig- 
nificant symptoms,  will  in  the  large  majority  of  cases  fail 
to  infect  a  married  partner  or  transmit  syphilis  by  in- 
heritance. 

No  man  should  marry,  whatever  time  may  have 
elapsed  after  infection,  who  has  not  had  a  long  interval 
— at  the  very  least  six  months — of  absolute  freedom  from 
symptoms ;  and  the  reverse  is  true,  that  no  man  should 
marry,  however  remote  the  date  of  his  infection,  who 
bears  upon  his  person  active  symptoms  of  his  disease. 
There  are  subjects  of  syphilis  who  should  never  marry, 
though  these  are  few.  In  them  the  disease  has  induced 
a  cachexia  permitting  an  evolution  of  the  malady  to  the 
point  where  the  systemic  infection  is  too  profound  and 
too  persistent  to  permit  a  return  to  a  normal  standard  of 
health. 

When  syphilis  has  actually  been  transmitted  from 
husband  to  wife,  or  the  reverse,  and  the  two,  after  a 
reasonable  abstinence,  again  cohabit,  a  problem  of  some 
gravity  is  presented  to  the  physician.  As  a  rule,  sexual 
indulgence  between  such  consorts  should  be  postponed 
to  the  utmost  limit,  seeing  that  in  case  of  offspring 
the  chances  of  inheritance  of  the  parental  disease  are 
doubled  by  reason  of  the  infection  of  both  father  and 
mother.  Even  here,  so  provident  is  nature  for  its  well- 
being,  the  child  may  completely  escape ;  but  the  peril  is 
very  great.  In  this  case  husband  and  wife  should  be 
conjured  to  take  every  precaution  against  the  occurrence 


276      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

of  pregnancy;  and  the  only  safe  and  justifiable  precau- 
tion is  total  abstinence  from  sexual  indulgence.  Nor  is 
this  conscientious  denial  of  the  bodily  appetites  the 
Utopian  dream  of  a  social  reform  for  the  future.  Every 
physician  of  experience  has  had  knowledge  of  husbands 
and  wives  who,  impelled  by  a  high  sense  of  duty  to 
themselves,  to  their  families,  and  to  the  world,  have  lived 
for  years  in  asexual  companionship,  waiting  for  the  time 
when  their  physical  union  would  not  be  shadowed  by 
the  possibility  of  bringing  a  reproach  upon  themselves 
and  a  curse  upon  their  offspring. 

With  respect  to  the  question,  frequently  raised,  as  to 
the  insurability  of  the  infected  in  life-assurance  societies, 
the  companies  who  accept  risks  in  the  United  States  are 
not  as  yet  agreed  in  their  practice.  The  physician,  how- 
ever, who  examines  the  applicant  can,  when  the  exact 
facts  of  the  syphilitic  history  are  obtained,  make  a 
reasonable  forecast  of  the  longevity  prospects.  With  a 
history  of  mild  syphilis,  and  one  terminating  without 
appreciable  results  six  months  or  a  year  before  the  date 
of  the  examination,  the  forecast  is  decidedly  good. 
There  is  not  here  a  question  as  to  the  danger  of  trans- 
mission of  the  disease,  but  solely  one  of  longevity.  The 
longevity  prospects  of  the  average  of  the  infected  are 
better  than  the  companies  themselves  probably  believe. 
The  number  of  the  infected  subsequently  dying  of 
tuberculosis  or  of  carcinoma  is  exceedingly  small ;  and 
this  immunity,  as  the  later  acquisitions  of  science  sug- 
gest, is  related  to  the  inevitable  war  waged  between 
pathogenic  micro-organisms.  With  evidences  of  a 
recent  or  grave  syphilis  the  examiner  may  well  be 
cautious ;  but  even  here  there  is  little  prospect  that 
life  will  be  shortened  save  by  the  occurrence  of  some 
of  the  nervous  complications  of  the  disease. 

The  regulation  of  public  prostitution  by  law  with  a 
view  to  the  extermination  of  syphilis  has  long  been 
practised  in  France,  Belgium,  and  other  countries,  either 
generally  or  with  defined  limitations.     This   regulation 


SYPHILIS  AND   SOCIETY.  2JJ 

has  for  the  most  part  included  surveillance  and  peri- 
odical examination  of  the  persons  of  public  women,  with 
segregation  of  all  the  infected  by  the  aid  of  enforced 
hospitalism.  The  results  have  been,  from  a  scientific 
point  of  view,  in  a  high  degree  unsatisfactory.  It  is  a 
significant  fact  that  the  country  that  has  longest  regu- 
lated prostitution  by  law  has  also  furnished  the  most 
voluminous  literature,  and  until  a  recent  period  the  most 
authoritative  writers,  on  the  subject  of  syphilis.  The 
scheme  of  sanctioning  prostitution  in  any  way  has 
always  been  repugnant  to  the  commonwealths  inheriting 
the  traditions  of  the  Anglo-Saxon  race,  and,  now  that 
such  sanction  is  recognized  as  practically  valueless,  it  is 
in  the  highest  degree  improbable  that  the  United  States 
will  ever,  in  the  effort  to  solve  this  problem,  imitate  the 
practice  of  the  Old  World. 

The  proper  view  of  this  question,  as  of  most  of  the 
questions  connected  with  the  sexual  relation,  must  surely 
include  both  men  and  women.  The  law  which  demands 
a  periodical  examination  of  the  female  should  also  require 
a  periodical  examination  of  the  male  prostitute.  Every 
expert  to-day  recognizes  the  fact  that  the  syphilitic  male 
is  as  liable  to  disseminate  his  disease  as  his  companion  of 
the  other  sex.  If  one  must  exhibit  a  certificate  of  health 
before  sexual  congress  is  permitted,  so  should  the  other. 
If  one,  in  order  to  escape  the  penalties  of  the  law,  is  to 
secure  an  official  license,  so  should  the  other.  In  these 
closing  years  of  the  nineteenth  century,  when  women 
of  the  highest  character  and  intelligence  are  interesting 
themselves  in  this  subject,  no  sensible  person  can  doubt 
that  if  any  regulation  whatever  be  ordered,  it  will,  assur- 
edly in  America,  bear  equally  upon  both  sexes. 

But,  all  said  and  done,  the  representatives  of  advance 
in  social  science  should  clearly  recognize  the  fact  that 
syphilis  is  not,  as  has  been  claimed  by  a  class  of 
hysterical  writers  in  many  lands,  a  scourge  threatening, 
above  all  other  maladies,  the  devastation  of  the  human 
family.     Tuberculosis  annually  destroys  many  more  vie- 


2jZ      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

tims.  It  would  not  be  unjust  to  demand  that  the  State 
shall  ensure  the  fullest  security  to  life  for  the  residents  of 
large  cities,  in  the  way  of  provision  for  pure  water,  milk, 
ice,  food,  and  freedom  from  accidents,  before  it  attempts 
to  police  the  houses  that  are  visited  only  by  those  leading 
immoral  lives.  The  proportion  of  syphilitic  to  other 
diseases  in  no  part  of  the  world  exceeds  a  variation  of 
between  2  and  5  per  cent,  when  both  sexes  are  estimated 
in  the  statistical  returns.  Most  of  the  published  tables, 
unfortunately,  include  figures  obtained  from  army  and 
navy  hospitals,  where  men  only  are  sheltered. 

The  great  safeguard  against  syphilis  is  sexual  morality, 
without  which  no  safeguards  are  worthy  of  the  name. 
It  is  held  by  writers  that  for  young  men  this  is  too  lofty' 
an  ideal ;  but  such  objectors  have  no  practical  knowledge 
of  the  moral  standard  upheld  by  many  of  the  wisest 
thinkers  and  realized  by  thousands  of  self-denying  youths 
in  every  community.  The  physician  who  does  not  exert 
his  influence  in  the  interest  of  this  standard,  by  which 
men  and  women  alike  not  merely  protect  themselves 
from  these  maladies,  but  ensure  also  the  safety  of  the 
community  in  which  they  live,  has  yet  to  learn  the 
alphabet  of  sound  health. 


CHANCROID. 


Synonyms. — Soft  chancre ;  Simple  chancre  ;  Non- 
infecting  chancre  ;  Fr.  Chancre  mou  ;  Chancrelle  (Diday) ; 
Ger.  Einfacher  Schanker ;  Weicher  Schanker. 

Chancroid  is  a  contagious  venereal  disease  character- 
ized by  the  occurrence,  chiefly  in  the  genital  region,  of 
one  or  more,  often  several,  suppurating  and  ulcerative 
lesions,  due  to  the  presence  of  micro-organisms,  and  not 
ultimately  productive  of  specific  constitutional  symp- 
toms. The  secretions  of  a  chancroid  lesion,  when 
unmingled  with  those  of  syphilis,  are  never  succeeded 
by  the  symptoms  of  the  last-named  disease.  It  is,  how- 
ever, to  be  noted  that  both  the  virus  of  syphilis  and 
that  of  chancroid  may  be  implanted  at  one  moment 
upon  the  same  susceptible  point,  and  from  such  a  point 
the  phenomena  of  the  two  diseases  may  afterward  be 
evolved. 

The  establishment  of  an  absolute  distinction  between 
chancroid  and  syphilis  has  been  reserved  for  the  latter 
half  of  the  present  century.  For  a  long  time  after  the 
distinctive  differences  between  the  two  affections  were 
recognized  and  classified,  the  scientific  world  discussed 
with  energy  the  questions  respecting  "  the  unicity  or 
duality  of  the  chancrous  virus."  No  one,  however,  at 
present  holds  that  there  is  a  duality  of  the  syphilitic 
virus  or  of  chancre.  The  unicity  of  each,  to  employ  an 
outworn  phrase,  is  unquestioned.  But  it  is  certain  that 
there  is  a  contagious  venereal  disease,  local  in  its  effects, 
communicable  at  the  same  time  with  syphilis,  the  feat- 
ures of  which  may  be  confused  with  those  of  the  initial 
sclerosis  of  that  disease. 

To  demonstrate  without  possibility  of  error  that  an 

279 


280      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

individual  may  be  the  subject  of  even  a  grave  ulcerative 
lesion  which  is  never  followed  by  syphilis,  incurred  in 
sexual  exposure  of  the  genital  region,  may  be  named 
as  one  of  the  achievements  of  modern  science ;  but  a 
grievous  price  has  been  paid  for  this  knowledge  in  the 
errors  which  have  resulted  on  the  part  of  both  phy- 
sician and  patient.  Thousands  of  initial  scleroses  of 
syphilis  are  annually  mistaken  for  chancroids  ;  and  even 
the  onset  of  unmistakable  signs  of  systemic  syphilis, 
after  such  blunders  have  been  committed,  has  been  for 
a  time  ignored  or  misconstrued.  The  false  security 
engendered  by  over-confidence,  ignorance,  and  folly 
furnishes  the  background  for  a  historical  warning  which 
no  man  can  afford  to  ignore.  It  is  well,  at  the  very 
outset  of  a  study  of  soft,  non-infecting  chancres,  or 
chancroids,  to  realize  the  great  danger  of  confusing  them 
with  the  initial  scleroses  of  a  disease  whose  impress 
may  last  for  a  half-century,  and  whose  symptoms  may 
actually  be  intermingled  with  the  most  classically  devel- 
oped of  chancroid  ulcers. 

Etiology. — There  is  little  doubt  in  the  mind  of  any 
modern  observer  as  to  the  existence  of  a  specific  micro- 
organism which  is  the  effective  agent  in  the  production 
of  the  chancroidal  ulcer.  At  the  present  writing  the 
identification  and  the  recognition  of  the  etiological  value 
of  such  a  micro-organism  are  not  established.  The  proof 
of  existence  of  such  a  germ  rests  practically  upon  the 
same  basis  as  that  generally  assumed  for  the  agent  effect- 
ive in  the  production  of  syphilis.  That  the  discovery 
of  the  one  will  throw  a  flood  of  light  upon  the  etiological 
importance  of  the  other  cannot  be  doubted. 

At  the  present  time,  however,  there  are  not  wanting 
those  who  assert  that  the  effective  micro-organisms  of 
chancroid  are  simply  the  staphylococci  and  the  strepto- 
cocci which  are  concerned  in  the  production  of  pus  in 
general.  In  support  of  this  view  it  is  claimed  that  the 
peculiarities  of  the  chancroid  are  due  chiefly  to  the 
anatomico-physiological  characters  of  the  soil  in  which 


CHANCROID.  28 1 

it  chiefly  thrives — namely,  that  of  the  ano-genital  region 
of  the  cachectic  and  the  filthy ;  that  the  recognized  pus- 
organisms  are  found  in  all  cases  of  chancroid ;  that,  in 
spite  of  exhaustive  bacteriological  research,  no  other 
organisms  have  yet  been  demonstrated  as  capable  of 
producing  the  disease ;  that  the  results  of  inoculation 
of  the  skin  of  the  ano-genital  region  with  simple  pus 
are  not  distinguishable  from  chancroid ;  and  that  the 
secretion  of  such  artificial  lesions  is  capable,  like  that 
from  the  chancroid,  of  repeated  auto-inoculation. 

But,  per  contra,  it  is  to  be  noted  that  chancroids  at 
times  occur  in  those  who  are  neither  filthy  nor  cachectic, 
and  that  the  worst  results  may  be  exhibited  in  individuals 
of  a  healthy  class;  further,  that  while  inoculations  of 
simple  pus  (for  example,  that  from  an  acne  pustule)  have 
produced  lesions  scarcely  distinguishable  from  those  of 
chancroid,  yet  that  pus  even  from  these  sources  is  by  no 
means  always  of  the  "  simple  "  character  claimed,  since 
tubercle  bacilli  and  other  micro-organisms  little  sus- 
pected as  present  have  been  distinguished  in  pus  taken 
from  supposedly  innocuous  sources. 

The  clinical  argument  against  the  position  described 
above  is  very  strong.  A  periurethral  phlegmon  may 
burst  through  the  integument  of  the  penis ;  an  abscess 
of  the  vulvo-vaginal  gland  complicating  a  gonorrhoea 
in  women  may  open  through  the  vaginal  wall  near  the 
vulvar  orifice ;  a  large  pustule  of  the  skin  of  the  penis 
may  be  produced  by  the  presence  of  the  acarus  scabiei ; 
a  suppurating  balanitis  in  phimosis  complicated  by  a 
tight  stenosis  of  the  preputial  orifice  may  result  in  the 
practical  imprisonment  of  an  exceedingly  foul  purulent 
product;  and  in  uncomplicated  cases,  neither  in  any  of 
these  nor  in  similar  accidents  of  the  same  region  that 
might  be  cited  will  there  be  the  slightest  approach  to 
the  formation  of  a  chancroid.  Such  an  occurrence,  if 
well  authenticated,  would  at  once  revolutionize  all  the 
accepted  doctrines  in  this  field  ;  and,  to  push  the  pos- 
sibilities no  further,  were  simple  pus  sufficient  to  induce 


282      SYFHILIS  AND    THE  VENEREAL   DISEASES. 

a  chancroid  in  a  filthy  and  cachectic  subject,  the  sur- 
geons of  ships'  crews,  at  a  distance  both  in  time  and 
space  from  port,  their  sick  afflicted  with  scurvy  and 
attacked  with  vermin,  might  expect  an  outbreak  of 
lesions  which,  as  a  matter  of  fact,  are  never  seen  except 
when  sailors  have  been  recently  in  contact  with  public 
women  in  some  haven  of  entry. 

The  number  of  observers  claiming  to  have  identified 
the  micro-organism  of  soft  chancre  is  large.  At.  the 
beginning  of  the  list  are  the  names  of  Salisbury  and 
Didier,  and  these  names  are  followed  by  those  of  Luca, 
Ducrey,  Welander,  Krefting,  Strauss,  Jullien,  and  Unna. 
Most  of  the  later  authors  have  busied  themselves  with 
the  micro-organism  of  Ducrey,  a  short  and  thick  bacil- 
lus with  rounded  extremities,  occurring  in  groups  and 
chains  between  and -in  the  bodies  of  the  cells  themselves. 
It  is  readily  stained  with  alcoholic  solutions  of  fuchsine, 
methyl-violet,  and  gentian-violet.  Krefting  used  as  a 
staining  solution  16  grams  of  a  5  per  cent,  borax  solu- 
tion, 20  grams  of  a  saturated  aqueous  solution  of  methyl- 
violet,  and  24  grams  of  distilled  water.  Streptococci  and 
staphylococci  were  found  in  the  first  generation  only 
of  cultures,  rarely  in  the  fifth  or  the  sixth.  In  all  cases 
the  streptobacillus  of  Ducrey  was  recognized  by  these 
observers,  with  the  exception  of  Jullien  and  Strauss, 
who  were  unable  to  discover  it  in  their  examinations. 
The  determination  of  the  problem  is  for  the  time  being 
relegated  to  further  investigation. 

The  Lesions  of  Chancroid. — The  clinical  symptoms 
of  chancroid  depend  largely  upon  accidental  circum- 
stances, the  important  factors  being,  first,  contact  with 
neighboring  parts  (friction,  maceration,  etc.),  and  second, 
the  site  of  infection.  The  typical  chancroid  develops 
where  the  site  is  such  that  the  lesion  can  progress 
symmetrically  and  at  the  same  time  be  uninjured  by 
traumatism.  With  these  conditions  fulfilled  (as  after 
intentional  inoculation)  the  earliest  symptom  is  the  pro- 
duction of — 


Plate  20. 


■\- 


•V; 


\ 


1.   Hutchinson's  teeth.     2.   Bacillus  of  Ducrey  (Petrini  de  Galatz). 


CHANCROID.  283 

The  Pustular  Lesion. — This  lesion  develops  at  the  site 
of  infection,  first  as  a  minute  hyperaemic  macule  which 
is  evolved  in  twenty-four  hours  after  inoculation,  a  pin- 
point-sized vesico-pustule  appearing  within  forty-eight 
hours  after  and  being  surrounded  by  a  reddish  halo. 
Day  after  day,  progressively,  this  lesion,  when  protected, 
enlarges  and  changes  to  a  pustule  of  the  type  once 
described  as  "  ecthymatous,"  attaining  the  size  of  a  small 
coin. 

When  the  roof- wall  of  this  pustule  is  broken  and  its 
purulent  contents  are  carefully  removed  by  wiping,  the 
floor  of  the  original  chamber  may  be  recognized  as  an 
ulcer,  corresponding  in  circular  outline  and  dimensions 
with  the  original  pustule.  The  floor  of  this  ulcer  is 
covered  at  first  with  a  pultaceous  and  sloughy  deposit ; 
later,  as  repair  ensues,  it  assumes  at  first  a  violaceous 
and  velvety  aspect,  and  still  later  presents  the  features 
of  a  healthy  granulating  surface.  The  circular  walls 
are  steep  and  abrupt,  as  if  produced  by  a  sharp  punch. 
The  base  in  uncomplicated  cases  is  invariably  soft 
and  supple,  never  in  the  least  suggesting  the  stony 
hardness  of  a  typical  sclerosis  of  syphilis.  There  is 
usually  a  more  or  less  angry-looking  areola  spreading 
to  a  variable  distance  away  from  the  centre.  The  sup- 
puration, at  first  abundant,  becomes  decidedly  more 
scanty  as  the  stage  of  repair  approaches.  In  general, 
the  condition  is  one  of  inflammation  accompanied  by 
more  or  less  soreness  and  pain  of  the  part.  In  this 
respect  also  the  lesion  differs  from  the  commonly  pain- 
less induration  of  certain  scleroses  of  syphilis. 

The  Erosive  Lesion.  —  Here  the  modification  results 
from  the  early  removal  of  the  roof-wall  of  the  pustule 
by  an  accident  (softening  by  maceration  with  mucus, 
friction  of  contiguous  parts,  etc.),  or  from  infection  of 
a  site  where,  for  any  reason,  the  pus  produced  does  not 
become  chambered.  At  such  points  there  is  infection 
of  an  open  surface,  such  as  the  mouth  of  a  follicle,  the 
site  of  a  ruptured  herpetic  vesicle,  or  the  seat  of  a  slight 


284      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

trauma  (about  the  verge  of  the  over-stretched  anus, 
over  a  torn  fraenum,  etc.).  In  these  cases  the  lesion 
is  ab  initio  a  suppurating  ulcer.  Its  contour  is  rounded, 
oval,  or  conforms  to  the  accidents  of  site  to  be  named 
later.  The  pus  is  thick,  creamy-yellow  in  hue,  and 
when  removed  discloses  an  empurpled  floor  or  one 
covered  with  the  peculiar  wash-leather-like  slough,  re- 
sembling nothing  so  nearly  as  the  floor  of  a  typical 
gumma  after  bursting.  Occasionally  these  sores,  after 
exhibition  of  "  open  "  symptoms,  are  covered  with  an  ad- 
herent crust,  which  increases  in  size  as  the  ulcer  spreads 
beneath,  so  that  lesions  of  the  dimensions  of  a  large 
coin,  and  even  larger,  may  thus  be  formed.  The  cha- 
racter of  some  of  these  developing  and  crusted  chan- 
croids may  be  misapprehended  by  both  patient  and 
inexpert  physician,  who  may  be  applying  unguents, 
powders,  or  other  dressings  to  the  outer  surface  of  a 
large  crust  of  this  character.  The  removal,  however, 
of  such  a  crust  may  disclose  an  abscess  as  large  as  the 
section  of  a  hen's  egg,  with  characteristic  chancroidal 
ulcer  for  the  floor. 

Variations  of  chancroid  are  from  each  of  the  types 
described  above.  The  shape,  for  example,  may  be  altered 
greatly  by  the  infection  of  a  wound  or  of  a  point  situ- 
ated between  two  abruptly  elevated  mucous  sufaces. 
In  the  former  event  the  lesion  may  be  linear  (chancroid 
of  the  anus  or  fraenum)  or  dumb-bell-shaped  (as  when 
the  sore  begins  in  the  sulcus  back  of  the  corona  glandis 
of  the  penis  and  spreads  in  a  double  circle  over  the 
prepuce  and  glans). 

Number. — The  chancroid  may  be  single ;  but  it  is 
usually  multiple,  and  this  multiplication  may  be  enor- 
mous. Usually  no  more  than  from  four  to  six  lesions 
are  seen  at  one  time  upon  a  single  individual ;  but  in 
exceptional  cases  hundreds  may  be  counted,  as  when,  in 
women,  the  secretion  from  a  few  lesions  on  the  upper 
portion  of  the  vulva  flows  over  not  only  the  lower 
portion  but  the  entire  perineum  and  anus. 


Plate  21. 


LUh.Ansl  F.  Ri'ichhokJ .  Miini 


CHANCROID.  285 

Multiplicity  in  the  number  of  chancroids  depends 
chiefly  upon  auto-inoculability  of  the  secretion.  The  se- 
cretion of  the  initial  sclerosis  of  syphilis  is  non-auto- 
inoculable  save  in  those  cases  where  there  is  mixed  in- 
fection (with  chancroid),  or  irritation  of  the  lesion  by 
accidental  agencies,  causing  suppuration.  The  abun- 
dant pus  of  the  chancroid,  however,  furnishes  the  amplest 
material  for  ensuring  multiplicity  of  lesions,  not  merely 
(as  constantly  happens)  at  the  moment  of  infection,  but 
also  after  infection,  to  the  point  of  production  of  two 
or  more  chancroids  which  proceed  promptly  to  multiply 
when  contact  with  adjacent  parts  is  not  prevented. 

Size. — The  majority  of  chancroids  do  not  exceed  in 
size  the  section  of  a  large  bean ;  but  great  variation 
exists  between  the  extremes  of  the  minute,  pin-point- 
sized  lesions,  scarcely  attaining  average  dimensions,  and 
the  largest  ulcers,  which  may  considerably  exceed  in 
size  a  platter,  covering,  for  example,  a  broad  area  of  the 
skin  of  the  belly  and  spreading  downward  over  the 
inner  face  of  the  thigh. 

Duration. — The  persistency  with  which  a  chancroid, 
even  after  extensive  and  thorough  cauterization,  unfail- 
ingly pursues  its  career  of  evolution  and  involution  is 
one  of  its  distinguishing  features.  It  outlives,  as  a  rule, 
all  the  tissue-destruction  produced  by  an  ordinary 
abscess  of  the  region  where  it  occurs,  and  in  one  form 
or  another  it  commonly  consumes  a  definite  time  before 
its  last  traces  are  removed.  From  three  to  six  weeks 
may  be  said  to  be  the  average  duration  of  a  simple  and 
wholly  uncomplicated  case.  All  the  complications  of  the 
disease,  however,  may  prolong  its  term. 

The  chronic  ulcers  occurring  chiefly  about  the  genital 
region  of  the  lower  class  of  prostitutes,  but  seen  also  in 
men,  persisting  for  many  months  and  even  for  years, 
belong  to  a  special  category  which  will  be  described 
later.  Here  the  unusual  duration  of  the  disease  is  due, 
not  to  any  inherent  tendency  of  the  affection  to  prolong 
itself  indefinitely,  but  to  accidents  of  the  process. 


286      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

Incubation. — Properly  speaking,  there  is  no  period 
of  incubation  for  the  chancroid.  As  a  rule,  by  exceed- 
ingly careful  observation  with  a  lens  the  infectious  pro- 
cess is  made  evident  within  a  few  hours,  twenty-four  at 
most,  after  the  introduction  of  the  virus.  In  the  average 
of  loosely  observed  clinical  cases  patients  declare  that 
their  infection  became  evident  a  few  days  after  exposure. 
It  is  rare  that  chancroids  appear  later  than  the  tenth 
day  after  infection. 

Cases,  however,  are  not  wanting  where  the  first  symp- 
toms of  the  disease  become  apparent  two  or  three  weeks 
after  contact.  In  this  event  it  is  generally  believed  that 
the  virus  was  simply  deposited  on  the  surface,  not  en- 
countering a  follicle  whereby  access  was  obtained  to  the 
deeper  tissues,  and  that  later  by  its  presence  the  virulent 
secretion  excited  an  irritation  which  eventually  opened 
up  a  portal  to  the  lymphatic  system.  The  ease,  how- 
ever, with  which  chancroids  reproduce  themselves  after 
mere  contact  should  throw  discredit  upon  such  an 
hypothesis. 

By  far  the  most  acceptable  explanation  of  apparently 
long  "incubative"  periods  is  the  ignorance  of  the  patient, 
for  these  periods  of  time,  of  the  existence  of  the  disorder. 
Incredible  though  it  may  appear,  there  are  few  experts 
who,  after  recognizing  threatening  inguinal  adenopathy, 
are  not  guided  by  this  condition  to  exploration  of  the 
genital  region,  with  the  result  of  discovering  and  first 
pointing  out  to  the  patient  a  previously  unsuspected 
chancroid.  Often  a  minute,  pin-point-sized  lesion  is 
thus  found  lurking  in  one  of  the  pockets  by  the  side 
of  the  fraenum,  or  hidden  immediately  behind  it,  or  in 
another  unobtrusive  region.  It  should  be  remembered 
in  this  connection  that  many,  but  by  no  means  all,  of  the 
patients  displaying  these  symptoms  are  of  the  filthy 
class,  with  associates  of  similar  social  grade.  In  men 
of  this  type  it  is  not  rare  to  discover  a  remarkable 
toleration  of  the  uneasiness  produced  by  a  long-con- 
tinued accumulation  of  the  smegma  praeputii,  and  the 


CHANCROID.  287 

sensations  produced  by  chancroids  are  mistaken  by 
such  patients  for  the  pruritic  symptoms  induced  by  the 
mild  balanitis  which  retention  of  the  smegma  often 
excites. 

Subjective  Sensations. — From  what  precedes  it  will 
be  seen  that  the  chancroid,  as  distinguished  from  an 
infecting  sclerosis,  may  be  the  source  of  subjective 
symptoms.  These  symptoms  may  be  merely  pruritic 
or  may  be  of  the  grade  of  severe  pain.  Exceptions  in 
this  particular  are  noteworthy.  At  times  the  infecting 
chancre  of  syphilis  is  painful  and  the  chancroid  is  unpro- 
ductive of  sensations  of  a  morbid  character;  but  for 
the  majority  of  cases  the  chancroid  is  distinguished  by 
its  inflammatory  character  and  by  the  tenderness  and 
pain  associated  with  it.  These  symptoms  are  more 
pronounced  when  the  lesion  is  rapidly  progressing  as  an 
ulcer,  or  when — a  rare  accident  in  modern  practice — 
there  are  complicating  accidents  of  the  order  of  gangrene 
or  phagedena. 

Absence  of  Specific  Induration. — The  base  of  the 
typical  chancroid,  however  large-sized  and  deeply  ulcer- 
ated, is  invariably  pliable,  softish,  and  non-indurated. 
It  never  exhibits,  save  in  mixed  forms,  the  characteristic 
ivory-like  hardness  and  density  of  an  equally  typical 
initial  sore  of  syphilis.  There  may  be  inflammatory 
engorgement,  and,  after  extensive  cauterization,  a  marked 
thickening  of  the  tissues  on  which  the  ulcer  rests,  but  a 
truly  characteristic  hardness  is  never  produced  by  these 
means. 

While  this  is  true,  the  fact  remains  that  only  a  skilled 
touch,  and  even  that  in  doubtful  cases  only  after  repeated 
examination,  can  decide  accurately  upon  the  nature  of 
the  disease.  It  is  not  a  wholly  safe  procedure  to  base 
a  decision  as  to  the  character  of  a  venereal  sore  upon 
the  test  of  its  induration  at  a  given  moment  under  the 
finger  and  thumb  of  an  expert.  There  is  a  decided 
difference  between  a  voluminous  mass  of  infiltration  at 
the  base  of  a  simple  chancre  which  has  been  inflamed 


288      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

by  any  of  the  accidents  to  which  it  has  been  exposed, 
and  the  exceedingly  delicate,  parchment-like  induration 
of  the  syphilitic  chancre  in  some  of  its  least  pretentious 
types.  In  brief,  upon  the  presence  or  absence  at  any 
one  moment  of  induration,  or  what  seems  to  be  indura- 
tion, an  exact  diagnosis  cannot  invariably  be  based. 

Auto-inoculability  of  the  Secretion. — The  purulent 
secretion  furnished  by  a  typical  chancroid  is  indefinitely 
auto-inoculable  on  the  person  of  the  affected  individual 
— a  fact  repeatedly  demonstrated  by  the  occurrence 
clinically  of  lesions  in  regions  in  close  proximity  to 
chancroids.  Thus,  a  sore  situated  on  one  labium  is 
tolerably  sure  to  infect  a  corresponding  point  on  the 
other  side ;  a  chancroid  on  the  outer  face  of  the  scrotum 
often  is  reproduced  upon  the  portion  of  the  thigh  nat- 
urally in  close  contact.  It  thus  happens  that  scores 
and  even  hundreds  of  chancroids  are  found  in  filthy 
and  neglected  subjects  where  the  indefinite  auto-inocula- 
bility of  the  sores  has  been  in  no  way  inhibited.  That  the 
pus-corpuscles  are  chiefly  responsible  for  this  virulence 
would  be  suspected  on  a  priori  grounds,  even  had  it  not 
been  demonstrated  that  the  secretion,  when  deprived  of 
its  pus-cells  by  filtration,  is  either  non-inoculable  or 
produces,  when  any  results  at  all  are  obtained,  an 
atypical  lesion. 

In  this  connection  it  is  needless  to  do  more  than  set 
down  the  fact  that  in  the  early  part  of  the  last  half 
of  the  present  century  the  practice  of  so-called  "  syph- 
ilization,"  enthusiastically  lauded  in  Sweden,  was  based 
on  an  erroneous  interpretation  of  the  auto-inoculability 
of  the  chancroid.  By  practically  exhausting  the  power 
of  the  skin  to  react  against  a  great  number  of  artificial 
inoculations  with  chancroidal  pus  it  was  thought  that 
syphilis  was  eradicated.  The  doctrines  then  held  have 
long  since  been  abandoned,  and  the  practice  has  properly 
been  relegated  to  a  place  among  the  curiosities  of 
medicine. 

Location. — Chancroids   are   said    to    occur,    like    the 


CHANCROID.  289 

initial  scleroses  of  syphilis,  upon  any  portion  of  the 
integument  and  the  adjacent  mucous  surfaces ;  but  such 
statements  cannot  be  accepted  without  reserve.  Cer- 
tainly there  is  no  proportion  whatever  between  the  fre- 
quency of  extra-genital  infecting  scleroses  and  chan- 
croids, the  former  being  in  large  centres  of  population 
scarcely  a  curiosity,  and  the  latter  being  one  of  the 
rarest  of  all  experiences.  The  most  frequent  site  of 
chancroids  is,  with  overwhelming  preponderance,  the 
genital  region ;  and  the  aphorism  still  holds,  that 
chancroid  is  the  most  truly  venereal  of  all  the  diseases 
classed  under  that  title. 

In  men  the  most  frequent  sites  of  chancroids  are  the 
fraenum,  the  prepuce,  the  glans,  the  sheath  of  the  penis, 
and  the  tip  of  the  urethra.  In  the  last-named  region, 
however,  infecting  chancres  are  much  more  common.  In 
women  the  sites  of  common  occurrence  of  chancroids 
are  the  labia  majora  and  minora,  the  vestibule,  and  the 
mucous  membrane  of  the  vagina  near  the  ostium.  Anal 
and  perianal  chancroids  are  far  more  common  in  women 
than  in  men,  by  reason  of  the  readiness  with  which  the 
auto-inoculable  secretion  flows  over  the  perineum  to 
the  sensitive  and  readily  eroded  mucous  orifice  of  the 
anus. 

Extra-genital  chancroids  are  chiefly  found  upon  the 
mouth,  the  eyelids,  the  lips,  and  other  parts  of  the  face. 
They  are  among  the  rarest  of  all  venereal  lesions. 

Complications. — Mixed  Chancre. — The  subject  of 
chancroid  may  exhibit,  in  the  course  of  a  few  days  after 
exposure,  several  typical  lesions  the  result  of  simulta- 
neous infection  or  consecutive  auto-inoculation.  All  these 
lesions,  in  the  course  of  a  fortnight,  may  be  progressing 
toward  complete  involution,  when  one  of  them  (rarely 
more)  may  begin  to  assume  the  characteristics  of  an  initial 
sclerosis  of  syphilis,  general  symptoms  of  the  disease 
following  in  due  course.  These  cases  are  illustrations 
of  coincident  infection  with  the  virus  of  the  soft  chancre 
and   of  syphilis,   the   resulting   sore   being   of  the   type 

19 


290      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

commonly  termed  "  mixed."  Here  two  diseases  coexist, 
precisely  as  when  patients  of  the  lower  class  present 
themselves  at  the  public  charities,  suffering  at  the  same 
moment  from  local  evidences  of  syphilis,  blennorrhagia, 
and  infection  of  the  skin  or  of  the  mucous  membranes 
with  pyogenic  cocci.  For  details  of  the  mixed  chancre 
the  reader  is  referred  to  the  pages  of  this  work  devoted 
to  the  subject  of  syphilis. 

Vegetations  and  other  Lesio?is  of  the  Skin  and  the 
Mucous  Membranes. — Venereal  warts,  herpetic  vesicles, 
or  patches  of  mucous  membrane  affected  with  balanitis 
and  posthitis  may  coexist  with  chancroids,  and  at  times 
disguise  their  features  to  a  marked  extent. 

Phimosis  and  Paraphimosis. — These  affections  are 
frequent  complications  of  chancroid,  and  when  of  severe 
grade  often  produce  excessive  pain  and  distress ;  but 
the  results  are,  however  threatening,  commonly  not  seri- 
ous. In  some  cases  one  or  several  chancroids  are  im- 
prisoned beneath  an  irreducible,  enormously  swollen, 
purplish-hued  prepuce,  its  orifice  discharging  a  foul  and 
purulent  fluid  which  may  by  auto-inoculation  serve  to 
identify  the  character  of  the  imprisoned  lesions,  inacces- 
sible save  after  operative  interference.  There  are  often 
one  or  two  small,  tell-tale  chancroids  on  the  verge  of  the 
preputial  orifice,  indicating  the  character  of  the  lesions 
within  the  pouch.  At  times  the  distress  is  so  great  that 
the  glands  in  the  vicinity  enlarge  by  sympathy.  The 
"  mixed"  chancre  in  this  situation  speedily  betrays  itself 
by  a  sclerosis  which  may  often  be  detected  with  the  thumb 
and  finger  through  the  tissue  of  the  cedematous  and  em- 
purpled prepuce.  Often,  too,  in  public  practice  these 
conditions  are  complicated  with  gonorrhoea,  the  pus  of 
which  escapes,  with  that  from  the  sores,  through  the 
stenosed  preputial  orifice.  Sloughing  may  ensue  in 
unrelieved  cases,  but  it  is  an  exceedingly  rare  result, 
and  need  never  be  feared  in  any  properly  treated  cleanly 
patient.  In  a  severe  type  of  complicated  disease  the 
glans  penis  pushes  its  way  through  the  sloughing  upper 


CHANCROID.  29I 

limb  of  the  foreskin,  whose  tumid  and  dependent  lower 
limb  presents  the  odd  appearance  of  a  second  glans  at 
the  extremity  of  the  penile  organ. 

In  paraphimosis  the  result  is  different,  though  the 
tumefaction  may  be  fully  as  great,  and  the  destructive 
action  in  grave  cases  may  be  as  formidable.  In  severe 
paraphimosis  the  line  of  ulceration,  forming  in  an  effort 
to  relieve  the  tension,  spreads  at  right  angles  to  the  shaft 
of  the  penis,  in  the  sulcus  behind  the  proximal  roll  of 
cedematous  tissue.  When  chancroids  are  present,  it  is 
rarely  the  case  that  this  line  of  ulceration,  intended  to 
afford  relief,  does  not  suffer  infection.  In  serious  states 
the  ulceration  spreads  upward  over  the  integument  of 
the  organ,  fusing  several  of  the  chancroids  present  into 
a  single  gigantic  ulcer.  The  "  subpreputial  frill "  of 
writers  is  the  lower  limb  of  an  cedematous  prepuce,  in 
these  cases  often  retracted  and  beset  with  chancroidal 
ulcers. 

Phagedena. — This  complication  may  coincide  with  or 
be  succeeded  by  sloughing  and  gangrene — accidents 
exceedingly  rare  in  the  evolution  of  the  initial  scleroses 
of  syphilis,  and,  as  a  matter  of  fact,  in  the  practice  of 
modern  medicine  rare  even  in  chancroids.  When 
phagedena  occurs,  however,  it  is  a  serious  disorder  and 
is  usually  difficult  to  manage. 

In  these  cases  the  result  may  be  due  to  improper 
local  or  general  treatment  (violent  cauterization  ;  subjec- 
tion of  the  patient  to  the  action  of  mercury,  under  the 
impression  that  the  disease  is  syphilitic  in  nature,  etc.), 
filth,  cachexia,  struma,  and  the  other  causes  of  local  or 
general  deterioration  of  vigor.  There  may  be  extension 
of  the  ulcer  in  one  or  in  all  directions  by  a  serpiginous 
process  wherein  the  disease  spreads  by  virtue  of  its 
auto-inoculable  virus,  and  at  the  same  time  destroys  the 
tissue  in  its  path.  This  may  be  a  superficial  or  deeply 
spreading  process ;  it  may  be  relatively  rapid  or,  what  is 
more  common,  exceeding  slow  and  painful,  scarcely 
giving   rise  to  much  distress.     As   the  disease   spreads 


292      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

in  one  direction  it  may  heal  in  another ;  or  it  may  result 
in  the  production  of  a  large  area  of  ulceration,  with 
uneven  and  irregular  floor  covered  by  a  sloughy,  pulta- 
ceous,  and  adherent  mass ;  softish  base  ;  scanty  or  semi- 
purulent  secretion ;  abruptly  steep,  occasionally  under- 
mined, edges ;  always  without  sclerotic  induration  of  the 
base,  and,  however  long  its  duration,  never  followed  by 
the  signs  of  systemic  syphilis. 

One  well-marked  and  fortunately  rare  type  of  serpigi- 
nous or  chronic  chancroid  has  been  found  so  rebellious 
to  treatment  and  so  persistent  in  its  course  that  it  has 
been  regarded  by  some  writers  as  a  modification  of  true 
chancroid  in  the  direction  of  lupus.  Some  of  the  forms 
of  so-called  .esthiomene  unquestionably  belong  to  this 
category.  In  obstinate  cases  the  chancroid  persists  for 
a  year  or  more,  very  slowly  spreading  over  the  abdom- 
inal surface  upward,  or  downward  over  the  inner  or 
outer  face  of  the  thigh.  The  ulceration  may  spread 
superficially  or  deeply,  and  in  the  latter  case  may  even 
be  subcutaneous,  burrowing  immediately  beneath  the 
skin  or  the  fascia,  undermining  the  tissues  in  areas  of 
the  size  of  a  large  platter,  with  fistulous  tracts  uniting 
its  lines  of  subcutaneous  excavation,  the  latter  here  and 
there  communicating  with  the  surface  by  irregularly  set 
ulcerating  openings,  suggesting  the  "  man-holes  "  of  a 
system  of  sewerage.  Here  an  empurpled  integument 
covers  the  ramifications  of  the  burrows,  ridges,  and  open 
ulcers,  a  thin,  virulent  secretion  destroying  slowly  what 
it  touches.  These  features  together  furnish  a  charac- 
teristic picture.  This  severe  complication  of  chancroid 
occurs  chiefly  in  women,  particularly  among  filthy  pros- 
titutes, but  it  is  also  seen  in  men  and  among  those 
debilitated  by  alcoholism,  venery,  poverty,  hospitalism, 
and  cachexia. 

Gangrene,  when  it  complicates  chancroid,  is  usually 
so  promptly  destructive  of  all  parts  affected  that  it  often 
serves  at  once  to  end  the  specifically  morbid  process. 
Here  the  accident  may  be  rapid  or  slow  of  occurrence, 


CHANCROID.  293 

and  the  gangrene  may  be  superficial,  removing  merely 
the  sore  itself  and  the  tissue  on  which  it  rests ;  or  the 
process  may  be  deep,  the  slough  embracing  the  glans 
or  the  entire  body  of  the  male  organ,  even  the  testicles 
being  laid  bare  in  the  scrotum.  Here  a  blackish  or 
greenish-black  slough  is  seen,  involving  the  whole  or  a 
large  part  of  the  sore  and  the  tissue  upon  which  it  rests. 
This  complication  of  chancroid  is  distinguished  from 
phagedena  in  that  it  more  often  attacks  filthy  men  than 
women.  At  the  outset  there  is  usually  a  coincident  in- 
flammation of  the  surrounding  parts,  which  often  assume 
an  erysipelatous  appearance.  These  severe  accidents 
of  chancroid  are  very  much  rarer  in  modern  practice 
than  in  the  days  preceding  the  modern  methods  of 
asepsis. 

Lymphangitis  and  Lymphadenitis  (Bubo ;  Chan- 
croidal bubo ;  Chancroid  adenopathy ;  vernacular, 
"  Blue-ball ;"  Ger.  Virulenter  Bubo  ;  Fr.  Boubon). — In- 
flammation of  the  lymphatic  vessels  and  the  perivascular 
tissue  is  a  complication  of  chancroid,  as  also  of  the 
other  venereal  diseases.  It  is  rather  rare  as  compared 
with  other  accidents  of  the  disease.  When  the  inflam- 
mation is  well  marked  the  lymphatic  trunks  may  be 
recognized  as  tender,  indurated,  and  painful  cords,  of  the 
thickness  of  a  wheat-stalk  or  of  the  little  finger,  stretch- 
ing away  from  the  site  of  the  lesion  toward  the  inguinal, 
pubic,  or  crural  regions.  At  times  the  overlying  integu- 
ment is  unchanged  in  color,  at  others  it  is  of  an  erythem- 
atous hue,  and  in  extreme  cases  it  may  even  threaten 
to  burst,  as  in  the  case  of  the  glandular  disease  accom- 
panying the  same  process. 

The  lymphadenitis,  or  bubo,  of  chancroid  differs  from 
that  of  syphilis  chiefly  in  its  inflammatory  character  and 
its  marked  tendency  to  the  production  of  an  abscess  ter- 
minating by  bursting.  Primary  syphilitic  adenopathy, 
it  will  be  remembered,  is  characterized  by  the  involve- 
ment of  several  glands,  occasionally  of  but  one,  in 
anatomical    connection    with    the    region    of    infection. 


294      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

When  the  chancre  has  a  genital  site,  a  chain  ("pleiad") 
of  densely  indurated  glands,  each  of  nearly  the  size  and 
firmness  of  a  marble,  neither  painful  nor  tender,  can  be 
recognized  in  one  or  both  groins.  Save  in  the  case  of 
"  mixed  "  infection  none  of  these  glands  exhibits  a  tend- 
ency to  inflammatory  softening  or  degeneration,  as  in 
the  case  of  the  lymphadenitis  of  chancroid. 

When  the  bubo  accompanying  chancroid  threatens 
to  burst,  one  or  more  tender  and  painful  points  can  be 
discovered,  usually  in  the  inguinal  region,  representing 
the  sites  of  as  many  glands.  With  greater  or  lesser  rapid- 
ity, often  in  the  course  of  but  a  few  days,  all  these  points, 
but  more  often  one  predominantly,  enlarge  until  the 
glandular  character  of  the  tumor  becomes  evident,  with 
aggravation  of  the  pain  and  tenderness,  both  with  and 
without  motion  of  the  muscles  in  the  vicinity.  In  typical 
cases  the  gland,  at  first  merely  voluminous  and  movable, 
becomes  fixed,  and  the  overlying  skin  is  involved  in  the 
periglandular  inflammation,  being  then  dusky,  empur- 
pled, and  gradually  thinned,  precisely  as  in  the  case  of 
the  integument  covering  a  syphilitic  gumma  about  to 
burst.  Then  follow,  in  course,  fluctuation,  softening, 
rupture  of  the  capsule  of  the  gland,  which  becomes  con- 
verted into  an  abscess,  and  escape  of  the  contents  either 
into  the  neighboring  subcutaneous  tissue  or  externally 
through  a  rent  in  the  skin.  When  several  glands  coin- 
cidently  suppurate  a  single  enormous  abscess  may  result 
from  their  fusion.  The  pus  evacuated  spontaneously  or 
by  surgical  procedures  is  foul,  thick,  hemorrhagic,  and 
at  times  auto-inoculable,  as  in  the  case  of  the  pus  fur- 
nished by  the  original  chancroid.  The  abscess-cavity, 
when  examined  after  spontaneous  rupture,  exhibits 
undermining  pockets,  grayish,  pus-soaked  walls,  detritus 
of  tissue,  and  encroachment  on  the  cavity  by  other 
glands  in  the  vicinity,  either  threatening  suppuration  or 
only  incidentally  and  less  seriously  involved. 

In  some  cases  of  spontaneous  rupture  of  the  abscess 
the  lips  of  the  rent  speedily  become  inoculated,  and  the 


CHANCROID.  295 

resulting  sore  exhibits  all  the  evidences  of  an  enormous 
inguinal  chancroid,  its  long  axis  lying  irregularly  paral- 
lel with  the  line  of  Poupart's  ligament,  its  edges  steep  or 
undermined,  its  floor  pus-  and  slough-covered,  its  secre- 
tion foul,  its  ragged  lips  teased  with  every  motion  of 
the  thigh.  Many  of  the  enormous  chronic  chancroids 
already  described  as  supposed  varieties  of  lupus  origi- 
nate in  gigantic  ulcerations  of  this  character.  Under 
favorable  circumstances,  however,  with  patients  of  a 
sound  constitution  and  properly  treated,  the  phases  of 
repair  ensue  even  after  exhibition  of  serious  symptoms, 
and  the  result  is  eventual  cicatrization  with  the  produc- 
tion of  an  indelible  scar,  whether  surgical  interference 
be  or  be  not  employed. 

It  is  probable,  though  not  wholly  demonstrable,  that 
in  some  cases  threatening  buboes  accompanying  chan- 
croids undergo  a  species  of  abortion  by  resorption. 
Certain  it  is  that  the  glands  in  these  instances  may  en- 
large and  become  both  painful  and  tender,  with  the 
result  of  an  eventual  resolution  short  of  pursuing  the 
career  just  sketched.  Whether  in  all  these  cases  the 
buboes  were  of  the  type  commonly  denominated  "  vir- 
ulent," or  were  merely  inflammatory  and  sympathetic 
phenomena  accompanying  the  original  venereal  lesion, 
cannot  be  determined. 

The  symptoms  of  bubo  and  of  lymphangitis  are  as 
distinctly  marked  in  women  as  in  men,  but  the  rarity 
of  these  complications  among  women  is  remarked  by 
all  observers. 

In  men  buboes  occur  in  from  10  to  30  per  cent,  of 
cases  of  chancroid,  the  figures  changing  according  to 
the  class  from  which  the  author  collects  his  statistics. 
Hospital  patients  are  much  less  liable  to  exhibit  these 
complications  than  the  filthy  class  of  dispensary  out- 
patients in  large  cities.  In  private  practice  typical  bubo 
in  the  more  cleanly  classes  is  decidedly  rare,  and  may 
occur  soon  after  the  first  appearance  of  the  chancroid,  or 
may  succeed  complete  cicatrization  of  the  inguinal  sore. 


296      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

Occasionally  the  bubo  develops  with  typical  features 
when  there  has  been  no  suspicion  of  chancroid,  this 
lesion  being  discovered  later  lying  behind  or  near  the 
fraenum.  At  times  the  bubo,  in  consequence  of  decus- 
sation of  the  lymphatics,  forms  on  the  side  opposite  that 
on  which  the  sore  originally  appeared. 

The  etiology  of  bubo  is  in  part  obscure.  Exciting 
causes  are,  assuredly,  weakness  of  the  constitution,  filth, 
over-exertion,  improper  treatment  of  the  original  sore, 
neglect  of  the  implicated  region  aside  from  lack  of  clean- 
liness, and  enormous  multiplicity  of  lesions.  "  Virulent  " 
bubo  may,  however,  occur  when  none  of  these  supposed 
causes  has  been  in  operation,  though,  fortunately,  this 
event  is  rare. 

With  respect  to  the  presence  of  micro-organisms  of  an 
etiological  significance  in  the  pus  of  a  chancroid  bubo, 
and  the  possibility  of  reproduction  by  auto-inoculation, 
opinions  differ.  By  some  writers  it  is  held  that  typical 
chancroid  of  the  groin  caused  by  the  bursting  of  a  bubo 
in  that  region  results  from  inoculation  of  the  lips  of 
the  wound,  not  with  the  pus  originally  contained  in 
the  abscess-cavity,  but  with  that  furnished  by  the  yet 
unhealed  chancroid.  The  results  of  experimentation 
are  not  conclusive.  At  times  the  bubo,  however,  as 
already  seen,  develops  only  after  the  sore  has  healed ; 
in  such  cases,  of  course,  the  possibility  of  infection  of  the 
bubo  from  the  chancroid  is  set  aside.  In  these  cases,  as 
also  in  those  where  total  excision  of  the  chancroid  has 
been  practised  before  inoculation-experiments,  and  where 
the  pus  employed  in  such  experiments  has  been  with- 
drawn by  aspiration  from  an  unopened  inguinal  abscess, 
the  results  are  not  satisfactory.  It  has  already  been 
shown  that  the  micro-organism  of  chancroid  has  not  yet 
been  so  definitely  demonstrated  that  its  presence  or 
absence  can  be  trusted  in  the  determination  of  the  char- 
acter of  any  lesion.  Of  the  micro-organisms  of  Ducrey 
and  Unna,  which  are  unquestionably  identical,  it  may  be 
said  that  they  are  most  often  not  demonstrable  in  the  pus 


CHANCROID.  297 

furnished  by  a  chancroidal  bubo.  It  has  hence  been  in- 
ferred that  bubo  was  caused  by  some  ptomaine  resulting 
from  the  invasion  of  a  strepto-bacillus,  but  all  this  as  yet 
lacks  proof.  Whether,  then,  the  micro-organisms  them- 
selves or  their  toxines  are  conveyed  from  the  site  of 
infection  to  the  gland  or  glands  which  suffer  as  a  conse- 
quence, it  is  merely  certain  that  the  germs  and  their 
products  are  originally  related  to  the  infective  process, 
and  that  in  no  other  disease  do  inflammation  and  sup- 
puration of  the  lymphatic  glands  present  precisely  the 
same  picture  as  in  the  bubo  accompanying  chancroid. 

Diagnosis. — The  indications  of  importance  in  the  diag- 
nosis of  chancroid  are,  first,  when  practicable,  to  exclude 
positively  the  presence  of  syphilis,  either  in  initial  sclero- 
sis or  in  later  manifestations  of  systemic  disease ;  second, 
to  remember  that  the  possibility  of  mixed  chancre  clouds 
every  case  until  the  longest  period  of  incubation  of 
syphilitic  chancre  has  elapsed  without  symptoms  of  the 
disease ;  third,  to  recall  the  most  significant  character- 
istics of  the  chancroid,  which  are  its  occurrence  without 
an  incubative  interval,  its  lack  of  induration,  its  con- 
tinuously purulent  character,  its  multiplicity,  its  auto- 
inoculability,  its  inflammatory  symptoms,  and  its  bubo. 
In  all  doubtful  cases  the  decision  should  be  reserved 
until  a  definite  period  has  elapsed.  Periurethral  phleg- 
mon is  distinguishable  by  its  defined  outline  and  inflam- 
matory character,  its  frequent  complication  of  a  pre- 
viously existing  urethritis,  and  its  situation,  which  is 
usually  near  the  distal  extremity  of  the  male  organ  and 
in  the  body  of  the  corpus  spongiosum. 

In  distinguishing  between  venereal  lesions  (including 
chancroid)  and  non-venereal  disorders  of  the  genital 
region,  the  age,  occupation,  character,  habits,  and  ante- 
cedents of  the  patient  should  be  considered.  An  epi- 
thelioma of  the  penis  or  of  the  clitoris  is  rare  in  youth, 
while  a  majority  of  all  the  affections  acquired  in  the 
sexual  act  originate  in  the  second,  third,  and  fourth 
decades.     Patients  in  middle  life  with  no  venereal  ante- 


298      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

cedents  are  in  a  different  category  from  those  who  have 
suffered  from  repeated  attacks  of  urethritis  or  "  chancre." 
Commercial  travellers,  women  having  public  occupations, 
and  residents  of  large  cities  are  more  exposed  to  the 
accidents  of  genital  infection  than  are  those  who  live  in 
the  country  and  those  who  are  surrounded  by  the  safe- 
guards of  a  home. 

The  most  striking  differences  between  chancroid, 
syphilitic  chancre,  herpes  progenitalis,  and  a  few  of  the 
more  common  affections  of  the  muco-cutaneous  surfaces 
of  the  genital  region  are  exhibited  in  the  table  given  on 
pages  300-305. 

Treatment. — The  management  of  the  general  con- 
dition of  the  subject  of  chancroid  is  usually  simple. 
The  recumbent  position  is  required  in  all  severe  or 
threatening  cases,  especially  when  complications  exist. 
In  the  simpler  cases  no  internal  remedies  are  indicated ; 
in  others,  those  especially  complicated  by  the  occurrence 
of  phagedena  or  gangrene,  a  tonic  regimen  is  urgently 
required,  including  a  generous  diet  and  the  use  of  cod- 
liver  oil,  the  hypophosphites,  and  the  ferruginous  tonics, 
among  which,  in  this  connection,  the  potassio-tartratc 
of  iron  has  long  been  especially  esteemed.  Mercury 
and  the  compounds  of  iodine  are  in  unmixed  cases 
actually  harmful,  and  should  not  be  employed. 

The  local  treatment  of  chancroid  is  usually  pursued 
on  one  of  two  lines,  the  one  occasionally  supplementing 
the  other :  The  first  is  by  antiseptic  dressings ;  the 
second  aims  at  obliteration  of  the  lesion  by  surgical  or 
chemical  measures. 

Antiseptic  treatment  is  always  indicated,  and  in  the 
end  is  probably  the  most  satisfactory  for  the  majority 
of  all  cases.  By  this  method  the  sore,  as  soon  as  its 
character  is  fully  determined,  is  washed  frequently  with 
lotions  containing  either  boric  acid,  carbolic  acid,  or 
corrosive  sublimate — the  first  in  saturated  solution,  the 
second  in  the  strength  of  1  part  to  50,  the  third  in  the 
strength  of  1  part  to  1000  or  2000.     The  first  named  is 


CHANCROID.  299 

preferred,  and,  when  it  is  possible  to  immerse  the  entire 
organ,  should  be  employed  as  a  continuous  local  hot  bath 
of  the  temperature  most  grateful  to  the  patient.  When 
employed  intermittently,  the  immersions  or  washings 
should  be  made  as  often  and  for  a  space  of  time  as  long 
as  practicable.  Mercurial  and  carbolized  fluids  are  better 
employed  as  lotions. 

At  the  outset  all  crusts  should  be  removed  and  the 
pus  washed  away  in  warm  water  with  the  aid  of  soap, 
after  which,  so  far  as  possible,  the  pultaceous  floor  of 
the  ulcer  should  be  cleansed.  The  surface  may  then  be 
sprayed  with  peroxide  of  hydrogen,  with  a  I  to  2  per 
cent,  formalin  solution,  or  with  water  to  which  has  been 
added,  in  the  cup  of  the  atomizer,  from  10  to  15  drops 
of  iodized  phenol : 

J*. 


Acid,  carbolic, 

sj; 

Iodin.  tinct., 

f3ss; 

Glycerin., 

Spts.  vin.  rect, 

dd.  fsij  ; 

Aq.  dest, 

ad  sj.— M 

Sig.  For  external  use  only,  diluted. 

A  suitable  dressing  for  many  chancroids,  after  the 
sores  are  thoroughly  cleansed  in  the  manner  described 
above,  is  to  paint  each  lesion  thoroughly  with  a  saturated 
solution  of  pyoktanin  blue  in  distilled  water.  This  is  an 
entirely  painless  application,  is  in  a  high  degree  aseptic, 
and  is  often  speedily  followed  by  satisfactory  results, 
The  solution  dries  in  the  course  of  a  few  moments  after 
the  painting,  when  the  surface  of  the  sore  may  be  dusted 
with  one  of  the  powders  described  below. 

After  the  cleansing,  however,  a  dry  or  a  wet  dressing 
of  a  different  sort  may  be  employed.  The  former  answers 
well  for  most  cases,  the  ulcer,  when  dried,  being  well  dusted 
with  either  europhen,  iodol,  aristol,  boric  or  salicylic  acid, 
or  hydronaphtol.  The  first  three  usually  answer  well ; 
the  fourth  and  fifth  named  are  sometimes  productive 
of  pain  when    applied    over   a  very  sensitive  sore,  and 


300     SYPHILIS  AND    THE    VENEREAL   DISEASES. 


Historv 


Etiology 


Incubative  stage 

Lesion : 
site 
character 


Chancroid. 
Occurs  in  subjects  of  syphilis  and  others;  prior  sexual 

exposure. 
Infection,  accidental  or  intentional,  by  medium  of  pus 

from  chancroid  or  chancroidal  bubo ;    usually  in  or 

near  the  ano-genital  region. 
None  after  actual  access  of  virus  to  lymphatic  channels. 

Lesion  rarely  later  than  one  week  after  infection. 

Most  commonly  genital ;   rarely  extra-genital. 
Pustulo-ulcerative  lesion  throughout;  few  exceptions. 


number  Multiple,  as  a  rule,  both  at  the  outset  and  by  subse- 

quent auto -infection.  Rarely,  though  at  times, 
unique ;   occasionally  veiy  numerous. 

color  Pustule  yellowish ;    ulcer,  when  wiped  clean,  florid ; 

crusts  greenish  and  blackish. 

contour  Round,  oval,  and,  when  fused,  circular. 


Subjective     sen-  Pain,  tenderness,  soreness,  occasionally  great  pain. 

sations 

If  ulcerating,  base  Engorged,  soft,   supple   when   not    cauterized,    rarely 
indurated, 

floor  Pus-soaked,  slough-covered  ;   showing  ragged  tags, 

edges  Abrupt,  steep,  punched-out ;  at  times  undermined. 

secretion  Foul,  pm-ulent,  hemorrhagic,  often  offensive  in  odor. 


crust 

Inoculability  and 
auto-inocula- 
bility 

Induration 


Career 


Accidents : 

lymphangitis 
bubo 


phagedena 
gangrene 


Bulky,  blackish-greenish ;  often  concavo-convex,  form- 
ing roof  of  a  pus-chamber. 

Auto-inoculable  indefinitely;  with  difficulty  transmitted 
to  animals.     Infection  of  genital  region  commonest. 

Base,  as  a  rule,  non-indurated;  supple;  if  inflamed, 
boggy,  indeterminate  in  outline,  non-elastic,  attached 
to  adjacent  tissue;  if  deeply  cauterized  or  irritated, 
at  times  indurated,  simulating  sclerosis  of  syphilis. 

Usually  in  uncomplicated  cases  a  cycle,  from  initial 
pustule  to  cicatrization,  of  from  six  to  eight  weeks. 
Resulting  indelible  scar. 

May  occur,  but  rare. 
In  one-tenth  to  one-third  of  male  cases. 
In  neglected  and  ill-treated  cases  not  rare. 
In  exceptional  cases  severe  and  even  grave. 


CHANCROID. 


30I 


History 
Etiology 

Incubative  stage 

Lesion  : 

site 
character 

number 


Chancre. 

Follows  infection  at  any  point  of  the  body,  usually  in 
non-syphilitic  subjects. 

Infection  with  syphilitic  virus  (sexually  or  by  accidental 
or  intentional  inoculation,  as  in  tattooing,  vaccina- 
tion, nursing  upon  the  nipple,  etc.). 

Usually  between  ten  and  thirty  days;  average,  twenty- 
one  days. 

Any  infected  region  of  the  body. 

Minute  plane  lesion  with  erosive  surface,  dry  or  moist 

papule,  or  large  tubercle. 
Usually  single,  rarely  multiple;    if  the  latter,  multiple 

at  the  outset,  and  not  by  later  auto-inoculation. 


color  Raw-ham;   dull-reddish;   scales  at  times  changing  the 

hue. 
contour  Highly  irregular,  observing  chiefly  the  peculiarities  of 

anatomical    site ;     when    on    a    free    plane    surface, 
usually  rounded  or  oval. 
Subjective     sen-     Often  entirely  wanting;  at  times  somewhat  painful. 

sations 
If  ulcerating,  base  Thin,  circumscribed,  or  enormous  and  well-defined. 


floor 


crust 

Inoculability  and 
auto  -  inocula- 
bility 

Induration 


Shallow,  erosive,  smooth. 

Scarcely  apparent;  often  ill-defined ;  at  times  elevated 

like  the  lips  of  a  small  crater  (Hunterian  type). 
Scanty  and   thin,  unless  accidentally  or  intentionally 

irritated. 
Scarcely  ever  formed. 

Non-auto-inoculable  save  in  "mixed"  infection. 


Characteristic;  marked;  thin  and  papery;  or  dense, 
ivory-like,  non-adherent,  movable,  insensitive  to 
pressure,    defined. 


Career  May  persist  for  months  after  general  symptoms  appear, 

or    may    practically    disappear    within    six    weeks; 
usually,    in    uncomplicated   cases,  no  scar  resulting. 
Accidents : 

lymphangitis   Occasionally  noticed;  then  painful. 

bubo  Characteristic  and  constant. 

phagedena       Almost  never  occurs. 

gangrene  Very  rare ;  occurs  only  in  cachectic  patients. 


302      SYPHILIS  AND    THE  VENEREAL   DISEASES. 


Chancroid. 

Systemic  results      In  protracted  cases  deterioration  of  general  health. 
Influence  of  Systemic  treatment  worthless ;  local  treatment  of  high- 

treatment  est  value. 


Date   of  appear- 
ance 
Symmetry 

Frequency 
Number    of    in- 
volved glands 
Size 

Inflammation, 
glandular  and 
periglandular 

Induration 

Career 

Infectiveness  of 

pus 
Diagnostic  value 

of   treatment 
Lymphangitis 
Situation 

Color  of  overly- 
ing integument 

Pain  and  tender- 
ness 

Career 


Bubo. 
At  any  time,  even  soon  after  healing  of  lesion. 

Usually  monolateral,  with  involvement  of  several  glands, 

one  predominantly;  occasionally  bilateral. 
One-tenth  to  one-third  of  all  cases  in  men. 
Often  one  gland  only,  rarely  more  than  two,  typically 

involved. 
From  large  nut  to  goose's  egg ;   at  times  as  large  as 

small  cocoanut. 
Classically   developed,  with   involvement  of  overlying 

integument,  heat,  pain,  redness,  and  swelling. 

Non-indurated. 

Resolution ;  or,  more  commonly,  suppuration,  with 
indelible  scar  resulting. 

In  cases  auto-infection  from  pus ;  in  others  non-auto- 
inoculability. 

General  treatment  unavailing ;  local  treatment  impera- 
tive. 

Rare,  but  of  occurrence. 

Usually  in  males,  along  dorsum  and  toward  root  of 
penis. 

Inflammatory  hue. 

Often  well  marked. 

Proceeds  to  resolution,  more  rarely  to  suppuration. 


Herpes  Progenitalis. 

History  Previous  recurrence  at  irregular  intervals  after  digestive 

disturbances,  venery,  uncleanliness,  and  other  sources 
of  general  or  local  irritation. 


CHANCROID.  303 

Chancre. 

Systemic  results  Occur  in  various  grades  of  severity  in  all  cases. 

Influence  of  Effective  at  an  early  stage, 
treatment 

Bubo. 

Date  of  appear-  Within  a  fortnight  after  development  of  initial  sclerosis. 

ance 

Symmetry  Bilateral  as  a  rule ;  at  times  symmetrical. 

Frequency  Constant.     At  least  one  gland  is  affected  in  every  case. 

Number    of    in-  Usually  several  glands,  one  or  both  sides  of  the  body. 

volved  glands 

Size  Uniformly  moderate,  cherry-  to  large-marble-sized. 

Inflammation,  None  in  uncomplicated  cases. 

glandular  and 

periglandular 

Induration  Firmly  and  densely  indurated. 

Career  Termination  by  resolution ;  scars  rarely  result. 

Infectiveness  of  No  pus,  save  in  mixed  cases. 

pus 

Diagnostic  value  General  treatment  effective. 

of  treatment 

Lymphangitis  Rare. 

Situation  Usually  in  lines  proceeding  from  site  of  sclerosis. 

Color  of  overly-  Rarely,  though  occasionally,  congested. 

ing  integument 

Pain  and  tender-  May  be  absent  or  as  severe  as  in  chancroid. 

ness 

Career  Rarely  suppuration ;   usually  resolution. 


Other  Local  Disorders  of  the  Skin  and  Mucous  Membrane. 

History  In  balanitis,  the  same  local  irritations  as  in  herpes;  in 

verruca,  usually  precedent  gonorrhoea ;  in  psoriasis 
and  eczema,  lesions  of  other  regions  ;  in  epithelioma, 
persistence  for  long  period  before  examination. 


304      SYPHILIS  AND    THE   VENEREAL   DISEASES. 


Etiology 


Herpes  Progenitalis. 

All  local  irritations,  chemical,  mechanical,  and  physio- 
logical, and  the  general  factors  producing  the  neur- 
oses. 

None. 


Incubation 
Lesion : 

character  Vesicles  and  sequels  of  vesicles 


number  Multiple,    as    a    rule ;     rarely   very    numerous,    often 

grouped,  occasionally  confluent. 


color 


Floors  of  broken  lesions  slightly  florid. 


Separate  lesions  rounded. 


subjective 
sensations 
If  ulcerating 


base 
floor 
edges 
secretion 
crust 
Inoculability  and 
auto-inocula- 
bility 
Induration 

Accidents  : 

lymphangitis 
bubo 


Tingling,  pricking,  itching. 

No  true  ulcer  forms.  When  ulceration  occurs,  there  is 
invariably  mixed  infection ;  at  times  exceedingly 
superficial  erosions  occur. 

Imperceptible. 

Smooth,  at  times  florid. 

Scarcely  appreciable. 

A  thin,  colorless  serum. 

Very  superficial  and  thin,  like  a  delicate  scale. 

Only  in  cases  of  mixed  infection.  . 


Absolutely  none;  pseudo-induration  produced  by  caus- 
tics, etc.  injudiciously  or  improperly  applied. 

None  save  in  mixed  cases. 
None  save  in  mixed  cases. 


phagedena       None  save  in  mixed  cases, 
gangrene  None. 

Systemic  results      None. 

Influence  of  Local  treatment  effective  in  two  or  three  days ;    general 

treatment  treatment  required  only  for  neurotic  and  gouty  states 

in  recurrent  cases. 


CHANCROID. 


305 


Other  Local  Disorders  of  the  Skin  and  Mucous  Membrane 
Etiology 


Incubation 
Lesion  : 

character 


number 


color 


subjective 
sensations 
If  ulcerating 


Local  irritations  in  eczema  and  balanitis ;  infection  in 
scabies;  irritating  secretions  (gonorrhceal,  etc.)  in 
verruca. 

None. 

Superficial  multiple  and  confluent  excoriations  in  balan- 
itis ;  pustules  in  eczema  and  scabies ;  scales  in 
eczema  and  psoriasis ;  warty  papules  or  plaques  in 
epithelioma;  warty  growths  in  verruca. 

Usually  multiple  in  all ;  occasionally  but  one  pustule  in 
scabies,  and  a  single  verruca;  often  patches  in 
eczema  and  psoriasis. 

Whitish  in  psoriasis ;  yellowish  in  scabies,  with  black- 
ish cuniculus;  reddish,  crimson,  and  purplish  in 
balanitis ;  florid  or  smeared  with  whitish  mucus  in 
verruca;    dull-reddish  in  epithelioma. 

Irregularly  rounded  excoriations  in  balanitis ;  defined 
patches  in  psoriasis  and  some  of  the  eczemas  ;  usually 
pedunculated  warts;  poor  definition  in  epithelioma. 

Itching  in  scabies  and  eczema ;  occasionally  burning 
in  epithelioma. 

Ulcer  only  in  late  stages  of  epithelioma  and  in  mixed 
infection  of  balanitis. 


base 

floor 

edges 

secretion 

crust 
Inoculability  and 
auto-inocula- 
bility 
Induration 
Accidents : 

lymphangitis 

bubo 

phagedena 
gangrene 

Systemic  results 

Influence  of 
treatment 

20 


Insignificant. 

Insignificant. 

Insignificant. 

Insignificant. 

Insignificant. 

Only  in  cases  of  mixed  infection.  Scabies  transmitted 
by  acari;  a  few  of  the  eczema  forms  are  infective 
from  the  presence  of  trichophyton,  mucors,  etc. 

None  save  in  well-developed  epitheliomatous  wart. 

None  save  in  epithelioma  of  advanced  grade. 

Occurs  in  severe  scabies  and  eczema  (adenopathy  of 

sympathy). 
Only  in  grave  epithelioma. 
Only  in  complicated  and  grave  epithelioma. 
None  save  cachexia  in  grave  epithelioma. 
Local  treatment  usually  effective  promptly  in  balanitis, 

verruca,  some   of  the  eczemas,  and  some  of  the  epi- 

theliomata  ;  psoriasis  often  obstinate. 


306    syphilis  and  the  venereal  diseases. 

hence  should  often  be  reduced  with  starch,  talc,  or  bis- 
muth. Hydronaphtol  is  usually  mixed  with  fullers'  earth, 
I  part  of  the  former  to  50  or  100  parts  of  the  latter. 
Iodoform  is  chiefly  valuable  as  a  local  narcotic,  but  it  is 
highly  objectionable  on  account  of  its  odor.  It  may  be 
ordered  for  patients  confined  to  the  room  for  a  brief 
time,  when  it  is  not  necessary  to  conceal  the  character 
of  the  disorder  from  others  visiting  the  apartment.  The 
deodorized  preparations  of  iodoform  are  not  preferable 
to  the  other  powders  named  above,  which  have  no 
specially  disagreeable  odor.  Calomel,  pure  or  mixed 
with  equal  parts  of  the  subnitrate  of  bismuth,  is  useful 
as  a  resort  where  other  preparations  do  not  answer  well. 
In  fact,  many  patients  exhibit  an  idiosyncrasy  with 
respect  to  these  local  applications.  After  the  antiseptic 
treatment  of  the  sore  wet  dressings  are  employed  by 
laying  a  pledget  of  lint  moistened  with  antiseptic  astrin- 
gent, sedative,  or  even  stimulating  solutions.  To  the  class 
of  preparations  first  named  belong  those  employed  in  the 
lotions  already  described ;  to  the  second  class  belong 
solutions  of  sulphate  of  copper  and  sulphate  of  zinc, 
10  to  20  per  cent,  strength;  to  the  third  class,  solutions 
of  cocain,  morphia,  arid  lead  (often  added  to  ingredients 
suggested  for  other  lotions),  as  well  as  the  black  and 
yellow  washes ;  in  the  class  last  named  are  included 
alcoholic  lotions,  embracing  the  aromatic  wine,  popular 
with  the  French. 

The  destruction  of  the  chancroid  is  wrought  by  the 
aid  of  the  actual  cautery  (Pacquelin  knife,  galvano- 
cauterization  apparatus,  hot  iron),  and  by  chemical 
agents,  including  nitric  and  pure  carbolic  acid,  zinc 
chloride,  caustic  potash,  cupric  sulphate,  and  the  nitrate 
of  silver.  The  last  is,  however,  ineffective  for  complete 
destructive  action,  and  is  chiefly  useful  as  a  stimulating 
application  to  sluggish  lesions,  for  which  purpose  it  is 
admirably  adapted.  Gaylord  recently  advised  a  40  per 
cent,  formaline  solution.     All  destruction  of  chancroids 


CHANCROID.  307 

by  these   methods  should  be  accomplished  with  strict 
antiseptic  precautions. 

The  operative  procedures  by  the  instruments  of  the 
surgeon  are  curetting  the  sore  itself  and  the  neighbor- 
ing tissue,  and  excision  of  the  part,  with  attempts  at 
securing  union — such  immediate  union  as  is  possible 
after  the  surgical  excision  of  simple  lesions  of  moderate 
size.  Both  methods  require  the  strictest  observance  of 
antiseptic  precautions,  and  both,  in  the  best  of  hands, 
have  been  followed  by  infection  of  the  resulting  wound, 
as  also  by  the  development  of  syphilis  in  cases  where 
the  diagnosis  was  not  well  established. 

The  objections  to  the  destruction  of  chancroids  by 
each  and  all  of  these  severe  measures  are  not  to  be 
lightly  set  aside.  They  may  briefly  be  summarized  as 
follows:  (1)  These  destructive  procedures  obscure  and 
aggravate  the  existing  local  disorder.  It  is  in  many 
cases  difficult,  if  not  impossible,  at  the  date  when  destruc- 
tion is  practised,  to  make  certain  that  the  case  is  not  one 
of  mixed  infection ;  and,  without  question,  initial  scle- 
roses thus  treated  are  apt  to  exhibit  excessive  induration 
at  the  base  of  the  sore.  No  practitioner  can  be  assured 
that  a  chancroid  will  not  be  complicated  with  syphilis 
until  about  one  month  has  elapsed  after  the  first  appear- 
ance of  the  lesion ;  hence  all  destructive  procedures 
undertaken  during  the  first  month  of  the  existence  of 
a  chancroid  may  be  disastrous  to  an  on-coming  syphilis. 
(2)  Many  of  these  operations,  even  when  performed 
with  the  utmost  care  and  repeated,  utterly  fail  of  accom- 
plishing the  end  in  view.  The  sore,  instead  of  becoming 
converted  into  a  simple  ulcer,  the  desired  issue  in  all 
attempts  of  this  class,  becomes  an  ugly  and  intractable 
lesion,  persisting  unaccountably,  often  without  exhibition 
of  classical  symptoms  of  chancroid,  the  despair  of  the 
inexperienced  and  the  horror  of  the  patient  after  the 
suffering  undergone  in  the  heroic  and  ineffectual  treat- 
ment to  which  he  has  been  subjected. 

On  a  careful  survey  of  the  field,  it  seems  probable  that 


308      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

destructive  treatment  of  chancroids  will  before  long 
follow  in  the  wake  of  the  now  practically  abandoned 
attempts  to  annihilate  the  syphilitic  chancre. 

Continuous  Immersion. — There  is  no  treatment  of  the 
threatening  or  actually  destructive  chancroid  comparable 
in  value  with  the  local  or  general  continuous  water-bath. 
Its  value  depends  upon  the  fact  that  the  pathogenic 
microbes  of  the  disease  lose  their  vitality  at  a  high  tem- 
perature which  is  tolerable  by  the  body.  The  patient, 
when  the  part  upon  which  the  sore  is  seated  can  be 
immersed,  spends  the  greater  part  of  the  wakeful  hours 
of  the  day  with  the  ulcer  wholly  submerged  in  water  as 
hot  as  can  be  tolerated ;  at  times  boric  acid  may  with 
advantage  be  added  to  the  bath.  In  other  cases  it  is 
much  easier  to  employ  the  sitz-bath,  in  which  the 
patient  partially  reclines  with  the  entire  ano-genital 
region  immersed,  the  water  of  all  such  baths  being 
maintained  at  a  high  temperature  by  the  aid  of  supplies 
from  a  source  of  heat.  The  patient  leaves  the  bath 
only  for  the  purpose  of  evacuating  the  bladder  and 
bowel.  In  all  grave  cases  both  the  night  and  the  day 
are  spent  in  the  water,  the  patient  being,  of  course, 
under  the  constant  supervision  of  a  trained  nurse.  The 
most  formidable  of  the  phagedenic,  sloughing,  and  gan- 
grenous lesions  with  destruction  of  tissue  are  thus 
readily  and  even  brilliantly  converted  into  healthy 
ulcers  which  speedily  assume  the  phases  of  repair,  if 
effective  constitutional  treatment  of  the  patient,  with 
proper  food  and  tonics,  be  at  the  same  time  secured. 
All  ointments  are  contraindicated  in  chancroids  in  a 
toxic  condition,  seeing  that  the  germ  of  the  disease  finds 
a  suitable  culture-field  in  these  greasy  applications  even 
when  they  are  medicated.  There  are  but  a  few  indica- 
tions for  their  employment ;  one  is  when  the  lint  over- 
lying the  dry  or  wet  dressing  adheres  so  firmly  to  the 
part,  in  consequence  of  the  discharges  which  leak  through, 
that  when  the  dressing  is  removed  there  is  bleeding  from 
the  edge  or  floor  of  the  ulcer.    Another  exception  relates 


CHANCROID.  309 

to  chancroids  of  the  urethra:  in  these  cases  the  lint  may 
be  spread  with  carbolated  vaseline — not  in  contact  with 
the  sore  itself,  but  merely  to  facilitate  removal  of  the 
dressings. 

Treatment  of  Complications. — Urethral  chancroids  may 
generally  be  exposed  by  the  aid  of  an  ear-speculum  or  a 
pair  of  urethral  forceps,  after  which  the  treatment  of  the 
sores  may  be  practised  as  in  the  case  of  those  existing 
in  other  regions.  Pledgets  of  lint  smeared  with  petro- 
leum jelly  and  medicated  with  one  of  the  powders 
already  named  may  be  inserted  in  the  urethra.  Urinat- 
ing with  the  penis  immersed  in  hot  water  is  of  great 
service  in  relieving  the  pain  of  micturition,  and  aids  in 
securing  repair  of  the  ulcer.  The  black  and  yellow 
washes,  pure  or  dilute,  may  subsequently  be  applied. 

Chancroids  complicated  with  phimosis,  the  sore  being 
so  imprisoned  that  it  cannot  be  exposed  within  the  sac 
of  the  prepuce,  are  usually  the  source  of  alarm  to  the 
patient  and  anxiety  to  the  physician,  but  the  real  danger 
in  any  case  is  much  less  than  is  generally  believed. 
With  the  aid  of  careful  syringing  of  the  sac  through 
the  preputial  orifice,  sufficient  cleanliness  of  the  surface 
of  the  sore  may  usually  be  secured  to  ensure  repair 
for  most  cases,  especially  as  lotions  may  be  employed 
about  the  integument  of  the  tumid  and  often  reddened 
and  empurpled  prepuce,  serving  to  still  further  reduce 
the  inflammatory  symptoms.  In  other  cases,  however, 
the  chancroid  becomes  threatening,  and  exposes  the 
patient  to  the  danger  of  a  slough  forming,  after  the  fall 
of  which  the  glans  escapes  through  a  species  of  button- 
hole through  the  swollen  and  distorted  prepuce — a  rare 
accident.  In  these  and  other  severe  cases  resort  must 
be  had  to  operative  procedures.  A  serious  objection, 
however,  is  the  danger  of  auto-infection  of  the  wound 
inflicted  by  the  surgeon.  As  a  rule,  therefore,  it  is  wise 
to  reserve  operative  interference  for  cases  of  emergency. 

Circumcision  of  the  prepuce,  or  incision  either  over 
the  dorsum  or  on  one  side  or  another  of  the  prepuce  (as 


3IO      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

advocated  by  Taylor),  may  be  practised  in  these  emer- 
gency cases ;  but  the  surgeon  will  always  do  well  to 
remember  that  in  the  best  of  hands  and  with  every  pre- 
caution infection  in  these  cases  has  occurred  repeatedly. 

The  operative  treatment  of  the  bubo  of  chancroid  is 
gradually  receding  into  the  class  of  reservations  advo- 
cated in  the  management  of  the  sore  itself.  Early  sur- 
gical treatment  of  these  complications,  once  indiscrimi- 
nately advocated  for  all  cases,  has  at  last  given  place  to 
a  more  judicial  waiting  for  the  evolution  of  the  malady 
to  the  point  where  intervention  is  inevitable. 

The  abortive  treatment  of  the  bubo  includes  rest  in 
the  recumbent  position  (which  is  perhaps  the  best  of  all 
measures  having  this  end  in  view) ;  hot  fomentations 
with  boric  acid ;  cathartics  and  a  restricted  diet ;  the 
local  application  of  leeches ;  and  applications  with  a 
view  to  a  resolvent  effect,  such  as  the  tincture  of  iodine, 
mercurial  ointment  (i  part  to  10  of  lanolin),  belladonna 
ointment,  and  salves  containing  the  salts  of  iodine,  as, 
for  example,  the  compound  iodine  ointment.  Pressure 
by  a  spica  bandage  and  by  the  application  of  bags  filled 
with  hot  shot  is  also  of  value.  The  common  treatment 
by  painting  with  tincture  of  iodine  is  by  most  experts 
practically  abandoned  as  useless.  The  internal  remedies 
employed,  such  as  sulphide  of  calcium  and  mercury,  are 
of  little,  if  any,  value. 

Injection  of  chancroidal  buboes  has  been  practised 
with  hot  solutions  of  boric  acid,  bichloride  and  benzoate 
of  mercury,  and  carbolic  acid.  Dangerous  results  have 
followed  some  of  these  injections,  and  those  containing 
the  mercuric  benzoate  have  in  cases  been  found  ineffec- 
tive. 

The  operative  treatment  of  bubo  is  by  free  incision, 
all  antiseptic  precautions  being  strictly  observed,  with 
excision  of  all  glands  wholly  or  partially  implicated  in 
the  morbid  process,  subsequent  curetting  of  the  surface, 
and  careful  washing  with  hot  borated  solutions.  The 
subsequent  dressings  are  with  iodoform  gauze.     These 


CHANCROID.  311 

operations,  when  carefully  practised,  are  followed  by 
exceedingly  satisfactory  results,  the  bubo  being  speed- 
ily converted  into  a  healthy  ulcer. 

As  the  resulting  scar  is,  however,  both  deep  and 
indelible,  and  ever  afterward  points  unmistakably  to  the 
nature  of  the  original  disorder,  efforts  are  constantly 
being  made  to  rob  these  procedures  of  some  of  their 
surgical  severity.  With  special  care  many  surgeons  in 
private  practice  now  succeed  in  penetrating  the  abscess- 
cavity  of  the  gland  with  a  fine  bistoury  or  a  large 
aspirator  needle.  The  evacuation  of  the  contents  by 
squeezing  is  followed  by  injection  of  a  hot  borated 
solution  or,  as  White  suggests,  of  iodoform  ointment. 
Aspiration  of  the  abscess  with  subsequent  injection  of 
hot  borated  water  often  suffices,  without  the  production 
of  a  serious  scar. 


DISORDERS  NOT  INVARIABLY 
VENEREAL. 


BALANITIS   AND   BALANO-POSTHITIS. 

Balanitis  is  an  inflammation  of  the  mucous  membrane 
covering  the  glans  penis.  It  is  usually  accompanied  by 
more  or  less  inflammation  of  the  prepuce  (posthitis). 

Etiology. — Balanitis  frequently  complicates  gonor- 
rhoea and  chancre,  but  it  may  occur  independently  of 
these  affections,  and  may  be  non-venereal  in  origin.  It 
is  caused  by  mechanical  or  chemical  irritation  of  the 
mucous  membrane,  and  it  most  frequently  results  from 
retention  beneath  a  long  prepuce  of  gonorrhceal  or  other 
pus  or  of  irritating  vaginal  or  other  secretions.  Neglect 
to  cleanse  the  parts,  permitting  the  normal  secretions 
to  decompose  and  become  irritating,  may  be  a  sufficient 
cause. 

Symptoms. — In  the  beginning  of  the  inflammation 
the  surface  of  the  glans  is  slightly  reddened  and  is 
covered  with  a  thin,  creamy  layer  of  mucus  and  pus. 
The  redness  rapidly  becomes  more  intense,  the  discharge 
thicker  and  more  profuse.  As  a  result  of  maceration  the 
epithelium  is  destroyed  in  patches,  leaving  irregularly 
outlined  excoriations ;  these  excoriations  are  usually 
superficial,  but  they  may  become  quite  deep  and  sim- 
ulate the  early  stage  of  chancroid.  The  inner  surface 
of  the  prepuce  usually  participates  in  the  process,  thus 
producing  a  balano-posthitis.  The  entire  body  of  the 
prepuce  may  be  inflamed,  with  slight  or  extensive 
oedema  and  tumefaction.  Inflammatory  phimosis — or, 
more  rarely,  paraphimosis — may  result.  The  inguinal 
glands  may  become  somewhat  enlarged  and  tender,  but 


BALANITIS  AND  BALANO-POSTHITIS.  313 

they  rarely  suppurate.  The  subjective  sensations  are 
usually  those  of  slight  itching  and  pricking,  most 
marked  in  the  sulcus  back  of  the  corona  ;  but  in  severe 
cases  the  glans  becomes  very  sensitive,  so  that  walking 
and  other  movements  of  the  body  are  painful  unless  the 
penis  be  carefully  supported  and  protected.  Scalding 
on  urination  is  usual,  especially  if  phimosis  be  present. 

With  a  long,  tight  prepuce  balanitis  may  become 
chronic ;  the  surface  is  then  red  and  velvety,  showing 
granular  or  even  warty  elevations. 

Diagnosis. — If  the  prepuce  can  be  retracted,  the 
diagnosis  can  usually  be  made  without  difficulty.  The 
excoriations  of  herpes  are  preceded  by  distinct  vesicles, 
and  other  portions  of  the  glans  are  not  inflamed.  When 
balanitis  follows  herpes,  the  history  of  the  disease  fur- 
nishes the  only  means  of  determining  its  origin.  Syph- 
ilitic chancre  and  chancroid  are  too  distinct  in  their 
characteristics  to  be  confounded  unless  they  are  com- 
plicated with  balanitis.  Careful  examination  will  detect 
the  induration  of  an  initial  sclerosis,  even  in  the  rare 
diffuse  forms.  The  ulcers  of  chancroid  are  much  deeper 
than  the  excoriations  of  balanitis,  and  the  pus  is  auto- 
inoculable.  In  severe  cases  of  balanitis  it  is  not  wise 
to  exclude  the  possibility  of  an  underlying  chancre  or 
chancroid  until  a  few  days'  treatment  has  reduced  the 
redness,  swelling,  and  infiltration  of  the  parts.  In  gonor- 
rhoea, when  the  prepuce  is  long,  and  especially  if  the 
preputial  orifice  be  filled  with  cotton  to  catch  the  dis- 
charge, the  pus  works  backward  and  covers  the  glans, 
producing  an  appearance  that  may  be  mistaken  for  balan- 
itis. Cleansing  and  inspection  of  the  parts  will  readily 
reveal  the  source  of  the  discharge. 

When  balanitis  is  complicated  by  phimosis,  an  accu- 
rate diagnosis  of  the  underlying  conditions  is  more  dif- 
ficult (see  Phimosis). 

Treatment. — The  treatment  of  balanitis  without  phi- 
mosis is  simple.  The  indications  are  to  keep  the  parts 
clean  and  free  from  pus,  and  the  inflamed  surfaces   dry 


314      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

and  separated  from  each  other.  The  prepuce  should  be 
retracted  and  the  parts  be  cleansed  in  simple  warm 
water  from  two  to  four  times  a  day.  From  3  to  4  per 
cent,  of  boric  acid  or  1  per  cent,  of  carbolic  acid  may 
be  added  to  the  water,  but  soap  or  other  irritating  sub- 
stances should  not  be  used.  After  washing,  the  parts 
should  be  dried  gently  by  patting  with  antiseptic  cotton  or 
with  a  soft  cloth,  and  covered  with  a  fine  dusting-powder. 
Over  the  powder  is  laid  a  thin  film  of  the  cotton  or  a  piece 
of  lint  cut  to  a  shape  and  size  that  will  just  cover  the 
glans  and  leave  the  meatus  free.  The  prepuce  is  now 
pulled  forward  to  cover  all,  and  the  dressing  is  complete. 
The  stearate  of  zinc  or  a  powder  containing  1  part  of 
boric  acid  and  from  2  to  4  parts  of  refined  talc  may  be 
used  in  most  cases.  Other  good  powders  are  calomel, 
bismuth,  or  zinc  oxide,  each  alone,  or  in  combination  with 
one  of  the  others,  or  reduced  with  talc.  In  severe  cases, 
when  the  surfaces  are  very  sensitive,  iodoform  is  excel- 
lent and  gives  relief.  Before  applying  the  powder  the 
surface  may  be  wiped  gently  with  a  solution  of  nitrate  of 
silver  (gr.  xx  to  5j  in  sj),  and  deep  excoriations  may  be 
touched  lightly  with  the  solid  stick. 

If  the  powders  are  not  productive  of  comfort,  the 
cotton  or  lint  may  be  moistened  with  a  mildly  astringent 
and  soothing  solution  before  it  is  applied  over  the 
powder,  or  the  latter  may  be  omitted  altogether.  Solu- 
tions of  carbolic  acid  (1  per  cent.),  boric  acid  (2  to  5 
per  cent.),  dilute  lead-water,  red  wine  (sj  to  gss  in  |j), 
or  the  following  may  be  used  : 

1^.  Zinci  sulphat.,  gr.  j— ij  ; 

Morph.  sulphat,  gr.  ss.  ; 

Atropin.  sulphat.,  gr.  \ ; 

Aquas,  ij.— M. 
Sig.  For  external  use. 

As  the  condition  improves,  powders  will  be  more  ser- 
viceable.    For  some  time  after  recovery  the  parts  must 


PHIMOSIS.  3 1 5 

be  cleansed  daily  and  the  surface  of  the  glans  and  the 
prepuce  be  separated  by  a  film  of  cotton. 

In  men  who  are  subject  to  frequent  recurrences  of 
balanitis,  the  mucous  membrane  may  be  rendered  less 
sensitive  and  less  liable  to  inflammation  by  the  long- 
continued  use  of  a  powder  containing  from  10  grains  to 
\  ounce  of  tannic  acid  to  the  ounce  of  talc,  starch, 
or  lycopodium. 

PHIMOSIS. 

In  severe  forms  of  balano-posthitis — usually  when 
secondary  to  chancre,  chancroid,  or  gonorrhoea — the 
swelling  and  infiltration  of  the  parts  may  be  sufficient 
to  prevent  retraction  of  the  prepuce  back  of  the  glans, 
thus  producing  an  inflammatory  phimosis.  If  a  man 
with  congenital  phimosis  more  or  less  complete  acquire 
a  venereal  disease,  inflammation  of  the  tissues  is  almost 
sure  to  follow,  since  cleansing  of  the  parts  is  very  dif- 


m 

Fig.  ii. — Phimosis  from  gonorrhoea  (Cullener) 

ficult,  and  irritating  discharges  are  retained  in  contact 
with  the  membrane. 

Symptoms. — The  swelling,  oedema,  and  inflammatory 
symptoms  may  be  slight,  giving  the  patient  little  incon- 
venience, or  they  may  be  severe  and  very  painful.  The 
distended  glans  is  then  covered  by  a  reddened,  sensitive, 
and  greatly  swollen  prepuce,  increasing  the  distal  ex- 
tremity of  the  penis  to  several  times  its  normal  size  and 
giving  the  organ  a  distorted  or  club  shape  (Fig.  1 1). 
The  discharge  escapes  from  the  narrow  opening  of  the 


316      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

prepuce,  and  may  dry  in  bulky  crusts  around  the  thick- 
ened edges.  Sometimes  there  is  excessive  oedema  and 
swelling,  with  but  slight  inflammation  and  discharge. 
Pressure  may  interfere  with  circulation  and  result  in 
gangrene  of  portions  of  the  prepuce  or  rarely  of  the 
glans.  Gangrene  first  appears  upon  the  inner  surface  of 
the  prepuce,  and  is  preceded  on  the  outer  surface  by 
evidences  of  interrupted  circulation — namely,  a  dark-red, 
livid,  or  bluish  color  of  the  skin.  If  left  to  itself,  the 
gangrene  usually  destroys  enough  of  the  prepuce  to 
release  the  glans  and  relieve  the  pressure ;  the  circula- 
tion being  thus  restored,  the  slough  is  thrown  off  and  the 
surfaces  cicatrize,  leaving  an  irregular,  ragged  prepuce. 

As  a  result  of  repeated  inflammations  the  prepuce 
may  become  permanently  thickened  and  hardened,  so 
that  its  retraction  is  impossible.  When  a  series  of  soft 
chancres  have  been  located  at  the  orifice  of  the  pre- 
puce, the  resulting  scars  may  contract  and  produce 
phimosis. 

Diagnosis. — An  accurate  diagnosis  of  the  underlying 
conditions  in  inflammatory  phimosis  is  difficult  and 
often  impossible.  When  syphilitic  chancre  is  present 
and  sufficiently  developed,  its  induration  may  be  felt 
through  the  prepuce,  and  typical  enlargement  of  the 
inguinal  glands  may  be  detected.  A  hidden  chancroid 
is  frequently  followed  by  one  or  more  chancroids  at  the 
orifice  of  the  prepuce,  the  result  of  auto-inoculation ; 
and,  since  the  retention  beneath  the  prepuce  of  infectious 
pus  favors  absorption,  such  a  chancre  is  apt  to  be  fol- 
lowed by  an  inflammatory  or  a  virulent  bubo.  In  doubt- 
ful cases  the  history  may  be  of  value ;  or  a  few  days  of 
treatment  may  reduce  the  swelling  and  inflammation 
and  render  an  accurate  diagnosis  possible.  If  gonor- 
rhoea is  present,  it  can  be  detected  even  when  the  meatus 
cannot  be  exposed.  The  preputial  sac  is  cleansed  by 
inserting  between  the  glans  and  the  prepuce  the  tip  of  a 
syringe  or  an  irrigator  and  injecting  an  aseptic  solution 
until  the  fluid  comes  away  clear.     The  patient  then  uri- 


PHIMOSIS.  317 

nates  in  one  or  two  glasses.     The  presence  of  pus  in  the 
urine  indicates  gonorrhoea. 

Treatment. — The  preputial  sac  should  be  irrigated 
three  or  four  times  daily  with  warm  water,  which  may 
contain  I  per  cent,  of  carbolic  acid  or  3  per  cent,  of  boric 
acid.  The  nozzle  of  the  syringe  or  irrigator,  gently 
inserted  between  the  glans  and  the  prepuce,  should  be 
directed  in  turn  to  every  part  of  the  sac,  and  sufficient 
fluid  should  be  used  to  cleanse  the  sac  thoroughly  of  all 
pus  and  other  accumulated  matter.  The  flat  nozzles 
made  for  this  purpose  are  excellent,  and  their  use 
excludes  the  possibility  of  injecting  the  urethra — a 
mistake  that  should  carefully  be  avoided.  The  cleansing 
of  the  parts  may  be  accomplished  less  perfectly  by 
wiping  out  the  sac  with  bits  of  cotton  wrapped  on  the 
ends  of  wooden  toothpicks.  After  cleansing  the  sur- 
faces one  of  the  soothing  or  astringent  lotions  recom- 
mended for  balanitis  may  be  injected  into  the  sac.  In 
the  large  majority  of  cases  a  few  days  of  this  treat- 
ment suffice  to  reduce  the  inflammation  and  to  render 
retraction  of  the  prepuce  possible.  If  swelling  and 
oedema  are  extensive  and  inflammatory  symptoms  are 
severe,  the  penis  should  be  immersed  for  twenty  minutes 
or  more,  several  times  daily,  in  hot  saturated  solutions 
of  boric  acid,  and  during  the  rest  of  the  twenty-four 
hours  should  be  supported  by  dressings  that  will  hold  it 
in  the  groin  or  over  the  pubes,  in  order  that  position 
may  favor  return  circulation.  If  gangrene  is  feared,  the 
patient  should  lie  on  his  back,  with  the  penis  supported 
and  constantly  wrapped  in  boric-acid  fomentations  as 
hot  as  can  be  tolerated.  Tonics  should  be  given  when 
indicated  by  the  general  condition  of  the  patient.  Cir- 
cumcision is  rarely  necessary,  and  when  performed  upon 
an  inflamed  prepuce  the  operation  gives  unsatisfactory 
results.  If  gangrene  is  imminent,  calling  for  immediate 
relief  of  pressure,  or  if  it  be  necessary  to  expose  a 
phagedenic  chancre  of  the  glans,  it  is  well  to  slit  up 
the  dorsum  of  the  prepuce.     If  soft  chancre  be  present, 


318      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

any  freshly  cut  surfaces  are  certain  to  become  infected. 
If  gangrene  has  begun  in  any  part,  pressure  should  be 
relieved  by  incisions,  hot  fomentations  should  be  applied, 
and  the  patient  should  be  kept  quiet  in  bed.  Quinine 
and  tonics  should  be  given  to  meet  the  indications  of 
each  case. 

In  adults,  congenital  phimosis  and  phimosis  due  to 
thickening  of  the  tissues  or  to  cicatricial  contraction 
should  be  treated  by  circumcision. 

PAEAPHIMOSIS. 
When  a  short  prepuce  becomes  inflamed  and  cedema- 
tous,  it  is  apt  to  roll  back  of  the  glans,  where  it  rapidly 
becomes  more  swollen  and  infiltrated  until  it  cannot 
be  returned  to  its  normal  position.  This  form  of  para- 
phimosis is  usually  mild  in  type.  A  more  serious  form 
often  occurs  where  a  longer  prepuce  with  a  narrow 
opening,  especially  if  rendered  yet  narrower  by  inflam- 
mation, is  slipped  back  of  the  glans.  This  may  occur  in 
coitus  or  in  cleansing  the  glans,  but  is  most  frequently 


Fig.  12. — Paraphimosis  (Cullerier). 

found  complicating  hard  or  soft  chancres  or  other  local 
disorder.  The  retraction  may  be  the  result  of  excessive 
swelling,  of  accident,  or  of  failure  to  return  the  prepuce 
over  the  glans  after  local  treatment  and  dressing. 

Symptoms. — In  spontaneous  paraphimosis  due  to  in- 
flammation of  a  short  prepuce  the  most  prominent 
symptom  is  the  mass  of  swollen  and  cedematous  tissue 


PARAPHIMOSIS.  3  1 9 

back  of  the  glans.  The  swelling  is  often  irregular  in 
form,  larger  below  than  above,  and  is  usually  soft,  puffy, 
or  doughy.  The  glans  is  but  slightly  if  at  all  affected, 
and  subjective  symptoms  are  wanting.  If  the  condition 
is  allowed  to  persist,  the  infiltration  of  the  tissues  may 
increase  until  the  swelling  becomes  tense,  white,  and 
glistening.  In  such  cases  the  glans  becomes  more  or 
less  swollen  and  darkened  in  hue,  showing  an  interference 
with  circulation.     Strangulation  rarely  follows. 

When  a  long  prepuce  with  a  tight  opening  is  re- 
tracted and  allowed  to  remain,  it  produces  constriction 
of  the  penis  back  of  the  glans,  which  soon  becomes 
turgid  and  livid.  The  soft  tissues  of  the  prepuce  in  a 
few  hours  become  greatly  inflamed  and  swollen.  Just 
back  of  the  glans  is  a  large  roll  of  tense,  glistening 
cedematous  tissue,  which  may  be  white  or  of  a  reddish 
color  (Fig.  12).  Back  of  this  roll,  and  often  concealed 
by  it,  is  a  deep  furrow  produced  by  the  constricting  band 
or  ring.  Behind  this  furrow  is  usually  another  smaller 
fold  of  swollen  and  cedematous  tissue.  At  first  these 
swollen,  cedematous  folds  are  soft  though  tense,  but  after 
a  few  days  plastic  infiltration  makes  them  thicker  and 
.firmer,  and  may  even  cause  adhesions. 

Strangulation  occurs  when  the  constricting  band  shuts 
off  all  circulation  from  the  parts  in  front.  The  glans  is 
then  even  more  swollen,  is  darker  in  color,  becoming 
purplish  or  almost  black,  and  is  cold  and  insensitive  to 
touch.  If  this  condition  be  untreated,  it  is  rapidly  fol- 
lowed by  gangrene  of  the  prepuce  or  of  the  glans. 
Fortunately,  in  the  large  majority  of  cases  gangrene 
destroys  the  constricting  band  in  time  to  save  the  glans. 

Treatment. — In  all  recent  cases  an  attempt  should  be 
made  to  return  the  glans  back  of  the  constricting  ring. 
If  reduction  is  not  accomplished,  and  there  is  no  im- 
mediate danger  of  strangulation,  rest,  elevation  of  the 
penis,  and  the  constant  application  of  boric-acid  fomen- 
tations will  promote  absorption  of  the  infiltration,  and 
will  in  almost  all  cases  render  further  operation  unnec- 


320      SYPHILIS  AND    THE   VENEREAL   DISEASES. 


essary.  In  addition  to  fomentations,  astringent  lotions 
may  be  used.  The  affected  part  should  be  watched 
closely  to  prevent  the  possibility  of  strangulation  and 
gangrene. 

If  strangulation  occur,  immediate  reduction  or  opera- 
tion  is    imperative.       If   an   even   pressure    be    exerted 

with  the  fingers  or  with  a 
narrow  bandage,  the  glans 
may  be  reduced  sufficiently 
to  enable  it  to  pass  through 
the  constricting  ring.       In 


Figs.  13,  14. — Reduction  of  paraphimosis. 

addition  to  pressure,  ice  or  iced  water  may  be  applied,, 
and  the  cedematous  fold  in  front  of  the  ring  may  be 
scarified  in  order  to  allow  the  serum  to  escape.  If 
these  measures  fail,  the  patient  should  be  put  under  the 
influence  of  an  anaesthetic,  when  the  resulting  relaxation 
of  the  tissues  greatly  aids  in  reducing  the  paraphimosis. 
The  corona  and  the  adjacent  portion  of  the  prepuce 
should  be  oiled,  and,  when  possible,  some  of  the  oil 
should  be  worked  under  the  constricting  band.  With 
the  thumb  and  the  forefinger  of  the  left  hand  encircling 
the  body  of  the  penis  just  back  of  the  stricture,  the  glans 
is  seized  with  the  thumb,  index,  and  middle  fingers  of 
the  right  hand,  and  by  them  squeezed  into  the  smallest 
possible  compass  (Fig.  13).  Pressure  should  be  exerted 
laterally,  in  order  so  to  reduce  the  diameter  of  the  glans 
that  the  left  thumb  and  forefinger  may  fetch   over  the 


VENEREAL   WARTS.  321 

preputial  constriction.  Sometimes  the  finger-nails  may- 
be worked  under  the  constriction,  and  thus  aid  in  the 
reduction.  Keyes  recommends  seizing  the  penis  behind 
the  strictured  prepuce  in  the  fork  of  the  index  and  mid- 
dle fingers  of  both  hands,  one  placed  on  each  side.  This 
method  gives  more  even  pressure  forward.  The  glans  is 
thus  compressed  between  the  two  thumbs  (Fig.  14).  The 
rounded  end  of  a  hair-pin  or  a  blunt-pointed  director 
may  be  inserted  under  the  constriction  on  each  side,  and 
the  glans  compressed  between  the  digits  while  the  pre- 
puce is  slipping  forward. 

With  the  patient  under  ether  reduction  can  be  accom- 
plished in  most  cases  if  sufficient  care  and  patience  be 
exercised  ;  but  if  all  attempts  fail,  it  is  necessary  to 
divide  the  constricting  band  of  tissue.  A  tenotomy-knife 
or  a  blunt-pointed  bistoury  with  the  blade  flat  is  inserted 
under  the  band.  When  possible,  the  blade  is  brought 
to  the  median  line  above  before  the  knife  is  turned  so 
as  to  bring  the  edge  upward,  and  the  ring  is  divided 
from  within  outward.  After  reduction  the  case  may  be 
treated  as  one  of  inflammatory  phimosis. 

In  reducing  paraphimosis  so  much  manipulation  and 
handling  of  the  parts  are  necessary  that,  in  case  a  con- 
tagious ulcer  is  present,  the  surgeon  is  in  danger  of  be- 
coming infected  unless  the  epidermis  of  his  hands  is 
sound. 

In  the  older  cases  of  paraphimosis  in  which  oedema  is 

the  chief,  if  not  the  only,  symptom,  rest,  position,  and 

warm  dressings  may  be  supplemented  by  the  application 

,of  pressure  and  of  strong  astringent  lotions.     For  such 

cases  Keyes  recommends  the  free  use  of  collodion. 

VENEREAL  WARTS. 
This  title  is  applied  to  vegetations  appearing  upon 
the  genitals  and  the  genital  region.  The  term  is  not 
strictly  accurate,  for,  while  these  warts  are  commonly  as- 
sociated with  venereal  diseases,  and  are  almost  always 
the    result    of    exposure    of    a    delicate    membrane    to 

21 


322      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

venereal  secretions  (gonorrhceal,  syphilitic,  leucorrhoeal, 
etc.),  the  lesions  may  spring  from  other  causes  (unclean- 
liness,  warmth,  and  moisture).  In  pregnant  women  they 
are  sometimes  found  bordering  the  vulva,  where  they 
are  doubtless  produced  by  irritating  discharges.  It  is 
possible  that  these  vegetations  possess  a  distinct  though 
feeble  contagious  element,  but  this  contagiousness  has 
never  been  demonstrated.  In  men  the  favorite  location 
of  venereal  warts  is  in  the  sulcus  back  of  the  glans  penis, 
but  they  are  found  over  all  parts  of  the  glans  and  the 
prepuce,  and  occasionally  within  the  urethra.  They  may 
also  appear  on  any  portion  of  the  penis,  scrotum,  per- 
ineum, and  inner  surface  of  the  thighs,  and  about  the 
anus.  In  women  they  are  commonly  found  over  and 
about  the  vulva,  over  the  perineum  and  anus,  and  some- 
times within  the  vagina.  They  may  be  single,  but  they 
are  usually  multiple,  and  they  vary  in  size  from  a  single 
filiform  projection  to  a  close  aggregation  of  filiform  or 
papillary  elevations  forming  a  mass  as  large  as  a  hen's 
egg  or  even  larger.  Individual  papillae  are  usually 
acuminate,  but  may  be  rounded,  club-shaped,  or  flattened. 
Instead  of  becoming  aggregated  in  larger  masses,  they 
may  appear  as  smaller  but  more  numerous  elevations ; 
at  times  hundreds  coexist  upon  the  genitals  and  the 
neighboring  regions.  They  may  so  fill  the  preputial  sac 
as  to  cause  phimosis,  paraphimosis,  or,  rarely,  gangrene. 
When  situated  on  a  free  surface,  where  they  are  dry, 
they  are  firmer  and  have  the  color  of  the  normal  skin, 
but  when  protected  and  moistened  they  are  softer,  are 
pinkish  or  bright  red  in  color,  and  are  covered  with  a 
whitish  or  yellowish  puriform  mucus  having  a  very 
offensive  odor.  The  larger  masses  may  be  peduncu- 
lated or  sessile,  and  form  irregular-shaped  vegetations  re- 
sembling in  appearance  cauliflower  or  the  comb  of  a  cock. 
Under  the  influence  of  warmth  and  moisture  they  grow 
luxuriantly  and  rapidly  by  peripheral  extension.  When 
larger  and  flattened  they  may  be  mistaken  for  condylo- 
mata.    The  latter  are  broader  and  flatter  than  venereal 


HERPES  PROGENITALIS.  323 

warts,  are  not  made  up  of  so  many  small  projections, 
and  are  found  in  connection  with  other  evidences,  or 
with  a  history,  of  syphilis.  Papillary  epithelioma  may 
be  distinguished  from  a  venereal  wart  by  the  indurated 
base  and  border  of  the  cancerous  growth,  its  slower 
development,  its  tendency  to  degenerate  and  to  form 
typical  deep  ulcers,  and  the  infrequency  with  which  it 
appears  before  the  fortieth  year. 

Treatment. — Cleanliness  is  first  in  importance.  In 
many  cases,  if  the  parts  be  kept  clean  and  covered  with 
a  simple  dusting-powder,  the  venereal  growths  gradually 
shrivel  and  disappear.  The  treatment  recommended  for 
balanitis  is  often  efficient ;  if  necessary,  the  lotions  and  pow- 
ders employed  in  that  affection  may  be  increased  in  strength. 
When  persistent,  pedunculated  masses  and  small  vegeta- 
tions may  be  removed  with  the  scissors  or  the  curette, 
and  the  base  cauterized  with  nitric  or  acetic  acid,  or  with 
nitrate  of  silver  in  stick.  After  such  treatment  the  sur- 
faces should  be  kept  clean  and  covered  with  stearate  of 
zinc,  iodoform,  aristol,  or  similar  powder.  The  large 
growths  with  a  broad  base  will  usually  shrivel  under  the 
application  of  tannic  acid  or  other  astringent  powder ;  if 
they  persist,  nitric  or  acetic  acid  maybe  applied  once  a  week 
until  the  base  is  destroyed,  a  powder  being  used  during 
the  intervals.  If  the  growth  can  be  kept  dry,  bichloride 
of  mercury  in  collodion  (3J  :  §j)  may  be  applied  every 
second  or  third  day.  In  using  this  preparation  care 
must  be  taken  to  prevent  its  contact  with  other  surfaces 
than  those  for  which  it  is  intended,  and  the  possibility 
of  balanitis  following  its  use  should  always  be  borne  in 
mind. 

HERPES   PROGENITALIS. 

This  disorder  is  not  always  venereal  in  its  origin,  but 
in  many  cases  it  follows  local  irritation  or  inflamma- 
tion caused  by  venereal  diseases.  Contact  with  irritating 
secretions,  lack  of  cleanliness,  excessive  venery,  sexual 
excitement,   constipation,   or  any  condition   that   causes 


324      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

congestion  of  the  parts,  favors  the  development  of  herpes. 
In  some  women  the  condition  frequently  accompanies 
the  menstrual  period.  A  long,  tight  prepuce  and  a  gouty 
or  rheumatic  diathesis  may  act  as  predisposing  causes. 
It  is  seen  occasionally  in  malaria.  Neurotic  individuals 
seem  to  be  unusually  susceptible  to  the  disease,  and  it  is 
highly  probable  that  the  immediate  cause  lies  in  some 
irritation  of  a  nerve  or  its  terminal  filaments. 

Symptoms. — The  disorder,  which  appears  in  the  form 
of  one  or  more  groups  of  minute,  pin-head-sized  vesicles 
on  an  inflamed  base,  may  affect  any  portion  of  the 
genital  organs  and  the  surrounding  integument  in  both 
sexes,  though  it  is  much  more  common  in  men.  In  the 
male  sex  it  is  most  frequently  found  upon  the  inner  sur- 
face of  the  prepuce,  in  the  sulcus,  or  on  the  glans;  in 
women,  on  the  hood  of  the  clitoris,  on  the  labia  minora, 
and  on  the  inner  face  of  the  labia  majora. 

The  eruption  is  accompanied,  and  may  be  preceded, 
by  sensations  of  burning,  pricking,  or  itching.  There  is 
usually  but  one  group  of  vesicles,  which  contain  a  clear 
fluid.  On  the  mucous  membrane  these  vesicles  rupture 
in  a  few  hours,  leaving  sharply  defined  circular  excoria- 
tions which,  if  unirritated,  heal  in  two  or  three  days 
without  other  treatment  than  cleanliness.  The  whole 
process  lasts  a  week  or  less.  When  the  vesicles 
are  situated  on  the  integument,  the  contents  dry  and 
form  small  crusts,  which  remain  for  a  few  days  until  heal- 
ing is  complete.  Sometimes  the  first  group  of  vesicles 
is  followed  by  others,  and  the  disorder  is  thus  continued 
through  several  weeks.  If  the  lesions  be  irritated  (by 
coitus,  severe  treatment,  etc.),  balanitis  may  follow,  and 
in  rare  cases  there  may  result  ulcerations  simulating  soft 
chancre,  with  inflammation  of  the  inguinal  glands.  One 
attack  of  this  affection  predisposes  to  others,  so  that  it 
is  commonly  recurrent,  appearing  periodically  or  at 
irregular  intervals  for  months  or  for  years.  The  persist- 
ency with  which  this  simple  disorder  recurs  is  not  only 
annoying  but  also  peculiarly  distressing  when  in  conse- 


HERPES  PROGENITALIS.  325 

quence  patients  believe  themselves  to  be  subjects  of 
syphilis.  In  the  hands  of  the  ignorant  or  the  unscrupu- 
lous these  deluded  victims  often  undergo  specific  treat- 
ment for  long  periods. 

Diagnosis. — The  excoriations  of  herpes  can  usually 
be  distinguished  from  those  of  balanitis  by  the  circular 
outline  of  the  herpetic  lesions,  which  is  rarely  entirely 
lost  even  when  the  vesicles  have  coalesced,  and  by  the 
absence  of  more  extended  inflammation.  When  the  ex- 
coriations suppurate  and  form  superficial  ulcers,  it  may 
be  impossible  to  distinguish  them  from  beginning  chan- 
croid, but  by  cleansing  the  parts  and  keeping  them 
covered  with  iodoform  or  aristol  herpetic  ulcers  will  at 
once  begin  to  improve,  and  in  a  few  days  will  be 
entirely  healed.  An  initial  sclerosis  may  appear  as  a 
small  excoriation,  but  underlying  induration  can  be  de- 
tected ;  the  sore  is  indolent,  and  is  soon  accompanied  by 
characteristic  enlargement  of  the  inguinal  glands.  In 
making  a  prognosis  it  must  be  remembered  that  chancre 
may  follow  in  the  site  of  an  herpetic  lesion  if  the  longest 
period  of  incubation  of  syphilitic  chancre  has  not  elapsed 
between  the  date  of  exposure  and  that  of  the  examina- 
tion. 

Treatment. — The  local  treatment  of  herpes  progeni- 
talis  is  that  of  balanitis.  Recurrences  may  often  be 
avoided  by  improvement  of  the  general  health  and  by 
hygienic  living,  including  abstinence  from  alcohol, 
tobacco,  and  highly  seasoned  food.  Local  and  other 
conditions  predisposing  to  congestion  of  the  parts  require 
treatment.  Sexual  hygiene  is  important.  In  obstinate 
cases  the  surface  of  the  glans  and  prepuce  may  be  hard- 
ened by  the  long-continued  use  of  tannic  acid  or  other 
astringent  in  powder  or  in  solution  of  water  and  alcohol. 


HYPOCHONDRIASIS. 


The  morbid  mental  states  produced  by  real  or  fancied 
venereal  disease  are  numerous,  and  are  equalled  only 
by  the  hypochondriasis  springing  from  ignorance  and 
perversion  of  the  physiological  functions  of  the  sexual 
•  organs.  These  morbid  mental  conditions  are  of  occur- 
rence in  both  sexes,  far  more  frequently  in  men  than  in 
women,  the  subjects  being  generally  near  the  puberal 
epoch.  The  symptoms  presented  differ  in  grade  of 
severity,  and  when  of  marked  character  they  may  result 
in  more  physical  distress  than  the  maladies. themselves, 
of  which  there  is  either  slight  evidence  or  a  mere  dread. 
For  practical  purposes  the  sexual  hypochondriac  and 
the  patient  in  terror  of  a  venereal  disease,  actual, 
possible,  or  wholly  imaginary,  may  be  considered  in  the 
same  category. 

It  is  a  matter  of  common  remark  that  the  physiology 
of  the  generative  organs  of  the  male  sex  is  less  under- 
stood by  the  average  physician  than  that  of  the  corre- 
sponding functions  in  women.  In  the  management  of 
the  youths,  commonly  unmarried,  who  are  sufferers  from 
the  mental  states  here  considered,  it  is  important  to  re- 
call the  following  facts  : 

Among  the  mammalia  of  the  lower  animals  the  sexual 
propensity  is  in  general  gratified  with  impunity  in  pro- 
miscuous relations,  the  young  males  copulating  with  in- 
dividuals of  the  other  sex  freely  on  the  earliest  impulse, 
when  not  restrained  by  stronger  adult  males  and  by 
females  who  are  not  ready  to  accept  approaches. 
From  this  event  dates  the  sexual  life  of  the  animal,  the 
male,  when  no  longer  capable  of  performing  the  sexual 
326 


HYPOCHONDRIASIS.  327 

act,  being  often  killed  by  stronger  and  more  ambitious 
rivals  or  being  abandoned  to  die  apart  from  the  group 
of  breeding  animals.  Throughout  this  sexual  life  the 
male  animal  has,  in  the  state  of  nature,  no  seminal  emis- 
sions and  no  perversion  of  controlling  sexual  instinct. 
As  a  rule,  he  refuses  to  solicit  the  female  of  his  kind 
when  she  is  pregnant.  In  many  cases  the  period  of 
activity  of  the  sexual  impulse  of  the  female  corresponds 
with  that  of  the  other  sex,  and  beyond  that  season  the 
two  often  exist  together  in  a  harmonious  asexual  life. 
Obviously,  this  arrangement  is  designed  solely  with  the 
view  of  reproducing  the  species. 

The  female,  as  a  rule  impregnated  at  the  earliest 
ovulation,  begins  with  this  event  a  sexual  life  which 
thereafter  consists  of  a  series  of  pregnancies  and  suck- 
lings of  offspring  until  she  is  incapable  of  further  concep- 
tion, when  she  also  either  dies  or  is  killed,  having 
fulfilled  her  part  in  the  struggle  for  existence.  There 
is  no  history  of  menstruation — a  function  which,  with  its 
important  accessory  phenomena  in  generations  of  trans- 
mitted tendencies,  distinguishes  the  female  of  man  alone 
in  the  animal  creation. 

When  man  is  studied  in  his  artificial  social  surround- 
ings, he  is  seen  at  once  to  be  amply  fitted  for  the 
part  he  is  to  play  in  life  of  a  broader  scope  and  deeper 
intent  than  that  of  the  brutes.  The  young  human 
male  is  required  by  the  written  and  unwritten  laws 
of  most  civilized  countries  to  deny  himself  the  grati- 
fication of  his  sexual  appetite  until  he  is  capable 
of  union  with  one  woman  and  of  providing  for  the 
support  of  a  family.  During  the  time  which  intervenes 
between  the  attainment  of  puberty  and  marriage  there 
is  a  period  of  unrest,  and  in  many  cases  even  of  physi- 
ological storms  which  ever  and  again  disturb  the  tenor 
of  his  days.  If  he  happens  to  be  among  the  large 
number  of  lads  who  early  in  life  have  practised  mastur- 
bation, a  perusal  of  the  advertisements  of  the  charlatan, 
with  their  record  of  horrors,  may  awaken  in  his  breast  a 


328      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

dread  of  a  frightful  future.  He  comes  to  his  physician 
or  friend  (well  for  him  if  the  former  be  also  the  latter) 
with  a  tale  of  involuntary  seminal  emissions  at  night, 
with  and  without  erection ;  an  escape  of  semen  when 
straining  at  stool ;  "  lost  manhood  ;  "  defective  memory ; 
spots  dancing  before  the  eyes ;  "  impotence ;"  sexual 
debility ;  general  weakness ;  and  disinclination  for 
society. 

With  the  trained  physician  it  is  scarcely  necessary  to 
discuss  this  group  of  "  symptoms."  Involuntary  noc- 
turnal discharges  of  semen  occurring  in  a  young  man 
several  times  during  one  night,  or  even  on  successive 
nights,  are  "  unnatural  "  simply  because  the  human  male 
animal  is  not  living  in  the  state  of  nature  briefly  sketched 
above.  These  losses  are  of  similar  import  whether 
occurring  with  erection  and  accompanied  by  a  lascivious 
dream,  or  in  the  total  unconsciousness  of  sleep.  They 
are  truly  physiological,  and  amount  to  the  price  paid  by 
the  youth  who  is  attempting  to  lead  a  correct  life  and 
who  refuses  to  lower  his  moral  standard.  The  frequency 
of  these  discharges  has  little  bearing  upon  any  question  of 
disease,  since  in  perfectly  sound  youths  seminal  losses  may 
be  even  often  repeated  without  detriment  to  the  general 
health.  A  frequency  at  one  time  is  usually  compensated 
for  by  a  relative  absence  at  another.  The  emissions  may 
be  followed  on  the  succeeding  day  by  a  feeling  of  lassi- 
tude, slight  frontal  headache,  and  mental  dulness,  but  the 
balance  is  always  struck  by  nature,  as  there  is  usually 
afforded  a  respite  from  the  sexual  fever  (if  such  it  may 
be  called),  when  the  discharge  or  the  series  of  successive 
discharges  is  at  length  for  the  time  being  made  to  cease. 
These  losses  wholly  correspond  in  physiological  function 
and  meaning  with  the  menstruation  of  the  young  woman, 
whose  monthly  flux  in  a  sense  represents  the  price  paid 
by  her  for  virginity,  clean  living,  and  a  delay  of  the 
performance  of  the  sexual  function  until  she  is  solicited 
in  marriage  by  an  acceptable  suitor.  It  is  true  that 
after  marriage  menstruation  may  occur  periodically,  but, 


HYPOCHONDRIASIS.  329 

as  a  rule,  it  is  suspended  during  pregnancy.  Married 
men  also,  temperately  indulging  in  sexual  relations, 
occasionally  have  periodical  involuntary  seminal  losses. 
It  is  well  known  that  the  comeliness  of  a  young  girl  is 
almost  proportioned  to  the  regularity  and  character  of 
her  monthly  periods.  None  the  less  is  it  certain  that 
the  attractiveness  of  a  youth  leading  a  clean  life — - 
that  which  makes  the  eye  of  man  and  woman  dwell 
on  his  person  with  a  sense  of  delight,  the  promise 
of  manhood  writ  large  on  his  features  and  figure — is 
to  a  degree  proportioned  to  his  involuntary  losses  at 
night. 

Nor  is  the  periodicity  observed  in  menstruation  not 
perceptible  in  the  corresponding  function  of  the  other 
sex,  seeing  that  not  only  are  married  men  at  certain 
seasons  of  the  month  specially  disposed  to  the  gratifica- 
tion of  sexual  desire,  but  that  the  unmarried  also,  at 
certain  times  in  the  month  more  than  at  others,  have  an 
access  of  similar  import.  There  is,  in  fact,  a  prostatic 
no  less  than  a  uterine  ebb  and  flow  of  sexual  congestion, 
and  the  reverse,  that  is  responsible  for  many  phe- 
nomena of  health  and  disease  perceptible  in  the  two 
sexes  and  often  wretchedly  misinterpreted.  Many,  in- 
deed, of  the  "  pollutions  "  of  young  men  at  night  (sug- 
gesting the  menstruation  of  women  not  accompanied 
by  ovulation)  are  discharges  largely  made  up  of  the 
prostatic  fluid  rather  than  of  semen. 

Much  the  same  explanation  can  be  given  of  the 
"  losses  at  stool "  on  straining  which  are  such  a  bugbear 
to  the  uninitiated.  These  losses,  too,  are  largely  made  up 
of  the  fluids  of  the  prostatic  sinuses,  expressed  by  pres- 
sure upon  the  gland  exerted  by  a  scybalous  mass  in  the 
rectum.  There  is  no  evidence  whatever  that  this  "  loss 
at  stool "  is,  in  the  life  of  any  continent  man,  a  sign  of 
disease.  Men  differ  greatly  in  the  quantity  of  prostatic 
secretion  they  furnish,  precisely  as  they  differ  in  the 
amount  of  salivary  fluid  supplied  during  mastication. 
There    is   no    fixed    standard    for    all    men,   as   there   is 


330      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

none  for  the  food  they  daily  eat  and  for  the  amount  of 
excreta  they  void  as  a  consequence  of  the  assimilation 
of  portions  of  that  food.  Indeed,  many  married  men, 
regularly  and  temperately  gratified  sexually,  find  a  nota- 
ble quantity  of  the  same  glycerin-like  secretion  at  the 
meatus  urinarius  after  stool  when  the  general  health  is 
absolutely  unimpaired  and  their  organs  are  in  a  normal 
state.  The  milky  fluid  seen  by  the  sexual  hypochon- 
driac when  actually  engaged  in  voiding  urine  is,  as  is 
well  known,  not  seminal  in  character,  but  is  due  to  the 
presence  of  the  alkaline  phosphates,  and  originates  in 
conditions  wholly  apart  from  the  sexual  organs.  The 
clearing  up  of  this  cloudiness  by  the  addition  of  a  small 
quantity  of  acid  in  the  presence  of  the  sufferer  is  usually 
of  value  in  restoring  his  mental  equilibrium. 

At  times  the  microscopical  examination  of  the  pros- 
tatic fluid  exuded  at  stool,  and  even  of  the  urine  of  the 
hypochondriac,  reveals  the  presence  of  spermatozoa. 
Even  here  no  evidence  is  presented  that  the  person  is 
the  victim  of  disease.  The  spinal  and  other  symptoms 
of  true  spermatorrhoea  need  not  here  be  considered.  As 
a  morbid  state  it  is  unquestionably  rare,  and  is  not  to  be 
classed  with  the  functional  derangements  of  the  puberal 
epoch  and  its  sexual  alternations  of  storm  and  calm. 

Masturbation  may  be  prolific  of  serious  physical  mis- 
chief; but  many  of  its  results  are  exaggerated,  and  for 
the  great  majority  of  youths  who  discover  the  nastiness 
arid  indecency  of  the  habit,  and  who  abandon  it,  no 
serious  consequences  ensue.  This  is  the  verdict  of  con- 
servative and  experienced  physicians  the  world  over. 
The  worst  of  its  results,  for  the  majority  of  men,  are 
mental — the  sense  of  unmanliness,  the  loss  of  self- 
respect,  and  the  dread  of  the  future  which  it  begets. 
The  best  recourse  in  this  morbid  mental  state  is  a  timely 
confession  to  a  wise  physician,  the  acceptance  of  some 
explanation  of  the  physiological  function  of  the  sexual 
organs,  and  the  receipt  of  a  good  deal  of  encouragement 
for  the  future.     The  youth  should  be  informed  clearly 


HYPOCHONDRIASIS.  3  3 1 

that  during  a  young  man's  period  of  sexual  probation 
he  has  a  constant  conflict  to  wage  between  his  passions 
and  his  better  self,  from  which  conflict  he  should  emerge 
a  victor — if  not  wholly  unscathed,  at  least  like  the  soldier 
who  has  made  a  brave  fight  and  has  conquered,  not 
without  some  resulting  scars,  the  enemy  that  sought  to 
vanquish  him.  The  best  of  fathers  and  husbands  are 
veterans  of  such  conflicts. 

"  Impotency  "  is  a  condition  of  which  a  great  number 
of  men  know  nothing,  however  eloquently  they  may 
bewail  its  occurrence.  Having  suspected  in  themselves 
some  weakness,  they  often  attempt  to  perform  the  sexual 
act,  chiefly  with  a  view  to  experiment,  and  the  novelty 
of  the  situation,  the  dread  of  failure,  or  the  fear  of  con- 
tracting some  disease  has  left  them  powerless ;  or, 
possibly,  when  engaged  in  fondling  and  caressing  a 
female  companion  they  have  experienced  a  flow  either 
of  the  prostatic  or  of  the  seminal  fluid  itself,  which  has 
persuaded  them  beyond  perad venture  of  a  "  sexual 
weakness "  with  which  they  are  afflicted. 

The  point  of  view  for  all  questions  of  this  order  is 
that  which  regards  equally  the  two  sexes.  The  inex- 
perienced youth  should  be  like  the  inexperienced  girl  in 
the  first  approaches  after  marriage — shrinking,  tremb- 
ling, timid,  and  unprepared.  It  is  estimated  that  from 
60  to  70  per  cent,  of  young  husbands  fail  in  the  first 
sexual  attempts  after  marriage,  and  whatever  figures 
may  here  represent  the  truth  must  surely  be  applicable 
to  the  other  sex.  The  truth  is,  that  while  the  young  of 
the  lower  animals  are  early  taught  by  experience  to  per- 
form the  sexual  act  without  dread  and,  in  the  wild 
state,  for  the  most  part  without  preference  of  individual, 
men  and  women  reared  in  civilization  and  surrounded 
by  the  usual  safeguards  of  social  order  require  to 
mutually  educate  each  other  in  the  matter  of  physical 
union.  Never  is  the  sexual  act  so  vigorously  and  effec- 
tively accomplished  as  when  the  strong  emotion  of  love 
unites  two  human  beings  and  elevates  the  performance 


332      SYPHILIS  AND    THE  VENEREAL   DLSEASES. 

of  the  brute  to  the  level  of  a  pure  morality.  Hence  the 
complaints  of  "premature  ejaculation  of  semen"  and  of 
"  failure  of  erection  "  on  the  part  of  the  hypochondriac 
have  no  meaning  when  interpreted  in  the  light  of 
science. 

The  "  lost  manhood  "  of  these  fond  youths  is  an  echo 
from  the  outgivings  of  the  parasites  of  the  profession. 
Manhood  in  its  best  sense  bears  small  proportion  to  the 
vigor  and  capabilities  of  the  sexual  organs.  In  so  far 
as  man  is  distinguishable  from  the  brutes  is  he  removed 
from  their  sexual  habits  and  powers.  The  lower  the 
individual  in  the  scale  of  civilization,  the  more  conspicu- 
ous, as  a  rule,  is  his  sexual  power  and  the  number  of 
resulting  progeny.  The  negro,  the  Indian,  and  the  half- 
breed  are  in  this  point  widely  removed  from  the  highest 
types  of  the  Anglo-Saxon.  Even  when  in  the  grasp  of 
disease,  the  tuberculous,  the  syphilitic,  the  leprous,  the 
idiotic,  and  those  burdened  with  the  inherited  and  ac- 
quired maladies  of  the  pauper  fetch  into  the  world  their 
superfluous  brood  to  be  a  burden  to  society  and  a  re- 
proach to  civilization ;  while  men  and  women  far  above 
them  in  the  social  scale,  and  superior  alike  in  point  of 
physical  endurance  and  mental  energy,  perform  the 
sexual  act  with  far  less  inclination,  frequency,  and  readi- 
ness. For  some  of  the  very  noblest  types  of  manhood 
and  womanhood,  indeed,  indulgence  in  the  sexual  act  is 
notably  infrequent,  the  resulting  offspring  few,  and  the 
marriage  state  often  unsought. 

The  listlessness,  loss  of  memory,  muscse  volitantes, 
and  lack  of  physical  energy  cited  by  the  hypochondriac 
as  evidences  of  his  condition  are  obvious  misinterpreta- 
tions of  the  changes  from  day  to  day  incidental  to  all 
active  lives.  The  fatigue  of  nervous  anxiety  is  not  neces- 
sarily morbid.  The  memory  of  some  of  the  insane  is 
remarkably  good ;  it  is  a  faculty  conspicuously  wanting 
among  some  of  the  greatest  men  of  history,  and  in  most 
persons  is  largely  the  result  of  their  education  and 
environment. 


HYPOCHONDRIASIS.  333 

"  Impotence "  is  a  word  that  for  the  expert  has  no 
longer  a  definite  meaning.  Every  healthy  adult  male  is, 
in  the  sense  in  which  that  word  is  popularly  employed, 
both  potent  and  impotent.  Some  men,  like  the  negro, 
are  capable  of  committing  a  rape  as  often  as  the 
occasion  offers,  merely  to  gratify  lust ;  fortunately,  they 
are  few  and  usually  meet  with  a  violent  end.  Fortu- 
nately, also,  the  best  type  of  man,  living  a  clean  life,  is 
wholly  unable  to  perform  the  sexual  act  save  with  the 
one  woman  in  the  world  whose  life  is  devoted  to  him 
alone.  For  the  men  within  these  two  extremes  a 
thousand  accidents — disgust,  anger,  excessive  bodily  or 
mental  fatigue,  recent  evacuation  of  the  seminal  vesicles, 
and  who  can  say  what  else — daily  render  them  "  im- 
potent"  in  the  sense  in  which  this  word  is  often  used. 

Nor  is  the  man  who,  living  a  clean  life,  chances  to 
possess  unusual  sexual  vigor,  for  this  reason  to  be  set 
down  as  a  type  of  superb  manhood.  With  infinite  fore- 
casting of  the  needs  of  the  race,  it  is  ordered  that  the 
sexual  propensity  be  most  eager,  most  energetic,  and 
most  effective  in  exercise  at  an  early  period  of  life,  when 
the  real  vigor  of  a  man,  mental  and  physical,  is  actually 
immature.  Obviously,  all  is  planned  with  a  view,  first, 
to  the  perpetuation  of  the  race,  and,  after  that,  to  pro- 
vision for  the  young  of  the  family  under  the  shelter  of 
the  roof  reared  by  the  strong  hand  and  provided  with 
sustenance  by  the  experienced  brain  of  the  maturer 
man. 

When  the  sexual  hypochondriac  oversteps  the  limits 
here  set — those,  namely,  within  which  a  fairly  healthy 
youth  passes  through  his  period  of  sexual  probation, 
with  a  heart  saddened  and  perhaps  affrighted  by  the 
ghosts  that  beset  his  pathway — then  he  enters  a  patho- 
logical field  which  cannot  be  named  without  a  sense  of 
disgust.  The  unnatural  practices  which  the  records  of 
history  teach  are  as  old  as  the  Saturnalia  of  the  Roman 
Empire,  prevail  only  to  a  limited  extent  in  our  own  day. 
Alienists,  chiefly  those  connected  with  state  institutions 


334      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

for  the  care  of  the  insane,  have  probed  the  depths  of 
this  vileness,  and  with  scientific  precision  have  analyzed 
the  symptoms  of  sexual  psychopathy  as  they  are  be- 
trayed in  masochism,  sadism,  tribadism,  sapphism, 
pederasty,  sodomy,  bestiality,  erotomania,  and  satyriasis. 

To  the  credit  of  humanity  it  may  be  added  that  these 
habits  are  often  manifestations  of  insanity  due  to  lesions 
of  the  nervous  centres.  The  victims  of  these  disorders 
are  the  frequent  subjects  of  epilepsy,  imbecility,  or 
dementia,  and  often  exhibit  microcephalic,  asymmetrical, 
or  scar-compressed  crania. 

Syphilophobia  is  a  term  used  to  describe  the  con- 
dition in  which  patients  become  morbidly  terror-stricken 
over  the  possibility  of  having  incurred  syphilis.  The 
term  may  be  used,  if  not  with  accuracy,  at  least  usefully, 
to  include  those  who  are  morbidly  anxious  lest  any 
of  the  venereal  diseases  other  than  syphilis,  such  as 
gonorrhoea,  have  been  incurred.  It  matters  not  what 
be  the  object  of  terror,  the  mental  state  is  practically 
the  same. 

It  is  seldom  that  in  the  venereal  diseases  any  more 
wretched  complexus  of  symptoms  is  presented  than  in 
a  well-marked  case  of  syphilophobia.  The  weird  of 
the  thing  seizes  alike  on  men  and  women,  and  while  it 
endures,  life  is  usually  embittered,  the  happiness  of  a 
home  often  blighted,  and  the  body  wasted  under  the  ner- 
vous strain.  Sleep,  digestion,  nutrition,  and  peace  of  mind 
vanish ;  the  tongue  becomes  dry,  the  eyes  haggard,  the 
person  neglected.  From  this  extreme  there  is  every 
gradation  to  the  other,  where  there  is  simply  a  short- 
lived and  happily-ended  anxiety.  Only  an  abounding 
selfishness  can  impel  men  to  these  conditions,  but  many 
patients  claim  that  their  unending  terror  is  based  on 
apprehensions  for  another — a  wife,  a  betrothed,  a 
daughter,  a  sister,  a  husband,  or  a  friend.  This  con- 
dition may  endure  for  but  a  few  days  or  weeks,  or  it 
may  last  for  years.  It  may  even  be  for  a  long  while 
shared  in  full  measure  by  a  consort.     In  a  few  cases  we 


HYPOCHONDRIASIS.  335 

have  seen  men  and  women  go  insane  under  the  burden 
of  the  anxiety.  In  these  extreme  instances  it  may  well 
be  believed  that  the  insanity  was  lingering  unrecognized 
until  the  accident  suggesting  fear  of  venereal  disease  be- 
came the  immediate  and  exciting  cause  of  the  disaster. 

The  bases  of  the  suspicions  of  these  people  are  widely 
different.  Some  individuals  exhibit  tangible  lesions  of 
the  surface,  which  they  choose  to  misinterpret,  after  a  real 
or  fancied  exposure  to  venereal  disease.  Thus  a  facial 
acne,  a  keratosis  pilaris  of  the  outer  faces  of  the  thighs 
and  arms,  a  telangiectasis  ("  spider  cancer ")  of  the 
surface  of  the  chest,  some  innocent  mollusca  of  the 
scrotum,  or  a  few  aphthous  ulcers  of  the  mouth  due  to 
indigestion,  serve  as  unmistakable  signs  of  syphilis. 
Often  in  their  restless  anxiety  these  victims  swallow 
medicaments  with  a  view  to  eradicating  the  malady  with 
which  they  are  convinced  they  are  infected,  and  these 
drugs,  by  the  production  of  a  medicamentous  rash,  add 
to  the  supposed  evidences  of  disease. 

When  no  lesions  are  present  on  which  to  build  these 
anxieties,  a  basis  is  readily  discovered  in  the  anatomical 
peculiarities  of  the  body.  In  this  way  the  bluish  tinge 
at  the  rim  of  the  corona  glandis  is  taken  to  be  a  sign 
of  "  gangrene ;  "  the  fungiform  papillae  of  the  tongue 
are  named  as  "  mucous  patches ; "  the  reddish  hue  of 
the  meatus  externus  urinarius  indicates  "inflammation." 
In  some  cases  the  testicles  are  too  closely  drawn  up  to 
the  body ;  in  others  they  are  too  lax ;  in  yet  others  the 
penis  is  shrinking;  in  women  the  vulva  is  beset  with 
"papules  "  when  its  follicles  are  unusually  conspicuous. 
If  these  unfortunates  once  become  possessed  of  works 
on  medicine,  they  are  usually  worse  distraught.  It  is 
not  at  all  surprising  that  even  classical  illustrations  of 
this  singular  craze  are  furnished  in  the  persons  of  physi- 
cians themselves.  The  subject,  even  though  it  seem  to 
have  a  ludicrous  side,  is  not  without  its  tragic  aspects. 
We  have  known  men  to  take  their  lives  in  despondency 


336      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

over  such  fancied  disorder.     The  trained  physician  must 
be  ready  to  appreciate  every  phase  of  the  madness. 

The  treatment  of  the  several  forms  of  hypochondriasis 
described  requires  the  utmost  skill,  prudence,  and  good 
judgment  on  the  part  of  the  physician.  The  chief 
remedy  at  hand  is  a  knowledge  of  the  truth.  This 
alone  is  often  sufficient.  A  common-sense  explanation 
and  a  little  encouragement  often  suffice  to  remove  a 
persistent  cloud  of  shame  and  dread.  Unfortunately, 
as  the  history  of  the  world  clearly  proves,  men  and 
women  will  not  always  listen  to  the  truth.  Sympathy 
does  good  at  times ;  at  others  it  is  worse  than  useless, 
and  ridicule,  even  scolding,  may  answer  the  end  better. 
For  the  obstinate  subjects  who  refuse  all  aid  of  this 
character  and  persist  in  retailing  their  long  list  of  symp- 
toms to  the  ear  of  the  physician,  he  may  even  make 
shift  to  accomplish  his  end  by  wholesome  threats.  It 
may  be  wise  in  cases  to  point  to  the  idiotic  condition 
that  occasionally  crowns  a  labor  of  the  sort  upon  which 
the  hypochondriac  is  engaged,  or  even,  as  a  last  resort, 
to  make  it  appear  that,  since  the  patient  will  listen  to 
neither  truth  nor  reason,  his  friends  must  be  made 
acquainted  with  the  facts  in  his  case.  The  last  is  often 
an  effective  argument.  It  is  a  pitiable  fact  that  some 
of  these  states  are  utterly  hopeless.  The  patients  either 
belong  to  the  insane  class  or  are  of  those  of  whom  it 
was  long  since  written  that  even  brayed  in  a  mortar 
their  folly  will  not  depart  from  them. 

For  the  young  male  sexual  hypochondriac  important 
advice  touches  his  moral  surroundings ;  but  over  and 
above  this  he  should  be  made  to  abandon  tobacco  and 
alcohol,  to  employ  the  flesh-brush  after  his  cool  morn- 
ing bath,  to  avoid  hot  and  Turkish  baths,  and  even  cold 
bathing  at  night,  which  is  apt  to  be  followed  by  undue 
stimulation  when  he  is  well  warmed  in  bed.  His  food 
should  be  nutritious  and  simple.  It  is  a  common  error 
for  these  young  persons  to  attempt  living  on  a  slim  diet 
to  avoid  stimulating  the  sexual  propensity.     All  medi- 


HYPOCHONDRIASIS.  337 

cines  of  the  sort  commonly  given  to  allay  nervous  ex- 
citability, such  as  bromide  of  potassium,  are  rigidly  to 
be  excluded.  For  these  subjects  they  are  vile  remedies, 
and  they  exert  an  injurious  effect  upon  the  mental  tone 
of  the  person  who  relies  upon  them.  From  a  scientific 
point  of  view,  they  are  given  with  a  wholly  false  con- 
ception of  the  end  to  be  attained.  The  bowels  should 
be  evacuated  daily,  and  there  should  be  open-air  living 
and  physical  exercise.  The  dance,  theatrical  perform- 
ances, club  life,  and  the  perusal  of  certain  kinds  of  liter- 
ature are  equally  harmful.  To  persons  of  this  class, 
medical  books  are  to  be  especially  prohibited. 


22 


ACUTE  URETHRITIS. 


The  term  "  urethritis  "  includes  all  forms  of  urethral 
inflammation.  By  far  the  most  common  of  these  inflam- 
mations is  gonorrhoea.  Cases  of  urethritis  originating 
without  the  influence,  direct  or  indirect,  of  gonorrhceal 
infection  are  not  common.  Urethritis  arises  sometimes 
from  other  forms  of  infection,  from  constitutional  defects, 
or  from  mechanical  or  chemical  injury  to  the  urethral  mem- 
brane ;  but  these  forms  of  the  disease  are  chiefly  interesting 
from  the  standpoint  of  etiology,  since  in  symptoms  and 
treatment  they  correspond  with  some  of  the  stages  of  the 
more  common  disorder.  In  the  following  pages,  except 
where  mention  is  made  of  other  forms  of  urethritis  or  of 
the  disease  as  it  occurs  in  women,  the  subject  under  con- 
sideration is  gonorrhoea  in  men. 

Unfortunately,  gonorrhoea  has  long  been  considered 
by  the  laity  and  by  the  majority  of  physicians  a  purely 
local  disease,  devoid  of  danger  to  health  or  life  except 
when  accompanied  by  local  complications,  such  as  epi- 
didymitis or  prostatitis,  or  when  followed,  in  improperly 
treated  cases,  by  stricture  and  the  resulting  disorders  of 
kidneys  and  of  circulation.  In  consequence  of  this  belief, 
the  chief,  and  with  many  physicians  the  only,  aim  of  treat- 
ment has  been  to  remove  a  disagreeable  discharge,  other 
and  more  serious  phases  of  this  really  formidable  disease 
being  entirely  overlooked. 

The  various  complications  of  gonorrhoea  are  considered 
in  succeeding  chapters.  It  is  important,  however,  before 
describing  the  disease,  to  impress  upon  the  minds  of  the 
physician  and  student  the  fact  that  gonorrhoea  not  only 
is  followed  frequently  by  serious  complications,  which 
may  result  in  local  deformities,  sterility,  stricture,  kidney- 

338 


ACUTE    URETHRITIS.  339 

disease,  arthritis,  sexual  neurasthenia,  and  other  forms 
of  chronic  invalidism,  but  also  may  be  the  direct  cause 
of  systemic  toxaemias  manifested  in  inflammation  of 
various  organs  of  the  body,  including  the  iris,  retina, 
peritoneum,  and  meninges,  or  may  produce  metastatic 
infection  and  destructive  inflammation  of  these  organs,  in 
some  instances  with  fatal  results.  The  gonococcus  has 
been  found  and  satisfactorily  demonstrated  in  the  blood, 
in  synovitis,  in  tendo-vaginitis,  in  abscesses  of  various 
glands,  in  endocarditis,  in  pleurisy,  and  in  other  inflam- 
mations developed  during  the  course  of  a  gonorrhoea. 
In  a  few  such  cases,  the  gonococcus  has  been  found  in 
the  blood. 

Much  evidence  has  accumulated  to  show  that  gon- 
orrhoea, with  or  without  the  aid  of  a  secondary  pus- 
infection,  is  directly  or  indirectly  responsible  for  some 
cases  of  neuritis,  myelitis,  meningitis,  and  other  disorders 
of  the  nervous  system,  including  locomotor  ataxia  and 
progressive  muscular  atrophy.  That  in  women  gonor- 
rhoea is  followed  very  frequently  by  severe  and  persistent 
pelvic  disease  is  a  fact  now  generally  recognized  by  the 
medical  profession. 

In  managing  a  case  of  gonorrhoea,  the  practitioner 
should  not  only  bear  in  mind  the  possible  serious  conse- 
quences of  the  disease  to  the  individual,  but  also  should 
remember  that  without  skilful  and  careful  treatment  the 
disease  has  a  marked  tendency  to  become  chronic,  and 
that  the  individual  is  often  capable  of  transferring  the 
disease  through  sexual  intercourse  long  after  all  ap- 
parent discharge  has  ceased  and  he  has  considered  him- 
self cured.  The  number  of  men  who  thus  unwittingly 
infect  their  wives  cannot  be  determined  accurately,  but 
the  list  of  innocent  victims  of  the  disease  is  certainly 
large.  It  is  the  duty  of  the  physician,  then,  not  only 
to  treat  his  patient's  gonorrhoea,  but  also  to  instruct 
him  regarding  its  attendant  dangers  to  others  as  well  as 
to  himself. 

Etiology. — Though  the  majority  of  all  instances  of 


340      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

acute  urethritis  is  due  to  direct  infection  of  the  urethra 
with  the  gonococcus,  cases  occur  as  a  result  of  infection 
with  other  micro-organisms  ;  and  yet  other  cases,  indistin- 
guishable clinically  from  gonorrhoea,  are  seen  in  which 
no  micro-organisms  can  be  found  by  present  methods  of 
investigation.  It  is  known  that  sterilized  toxines  obtained 
from  the  bodies  of  dead  gonococci  will  produce,  when 
injected  into  the  urethra,  an  acute  gonorrhoea.  It  is 
probable  that  other  toxines  and  chemical  agents  may 
produce  similar  forms  of  urethritis.  More  investigation 
is  needed  before  positive  ground  can  be  taken  regarding 
the  etiology  of  urethritis,  and  before  the  exceptional 
cases  can  be  definitely  classified  ;  but  in  general  the  disease 
may  be  divided  into  two  classes — infectious  urethritis 
(including  gonorrhoea,  pseudo-gonorrhoea,  syphilitic 
urethritis,  and  urethritis  tuberculosa)  and  non-infectious 
urethritis. 

i.  Infectious  Urethritis.  —  i.  Gonorrlioea  (your], 
semen,  and  pstv,  to  flow). — Synonyms :  Urethritis  ;  Clap ; 
Blennorrhagia  ;  Blennorrhoea  ;  Gleet ;  Germ.  Tripper  ; 
Schleimfluss  ;  Unreiner  Fluss  ;  Gonorrhoe ;  Fr.  Blen- 
norrhagie ;  Gonorrhee ;  Chaudepisse ;  Span,  and  Ilal. 
Gonorrea. 

The  term  "gonorrhoea"  is  a  misnomer,  but  it  has 
been  so  long  employed  in  a  specific  sense  that  it  must 
be  retained  for  the  present  rather  than  be  supplanted  by 
one  more  scientific.  Of  the  three  diseases,  syphilis,  chan- 
croid, and  gonorrhoea,  the  last  is  the  most  correctly  termed 
venereal,  for  it  most  frequently  results  from  sexual 
intercourse,  and  is  rarely  acquired  in  any  other  way. 
Simple  contact  of  a  gonorrhceal  discharge  with  the 
mucous  membrane  is  sufficient  in  the  large  majority 
of  cases  to  communicate  the  disease,  though  the  vagina 
is  less  easily  infected  than  the  urethra,  and  some  persons, 
particularly  under  special  circumstances,  are  less  suscep- 
tible than  others.  The  general  condition  of  the  indi- 
vidual, the  state  of  the  mucous  membrane  exposed  to 
infection,  and  the  circumstances  of  the  exposure,  other 


ACUTE    URETHRITIS.  34 1 

than  the  presence  of  a  gonorrhoeal  discharge,  play  a 
much  less  important  part  than  in  the  other  venereal 
disorders.  A  man  who  exposes  his  urethra  to  a  gonor- 
rhoeal discharge  has  few  chances  of  escaping  infection. 
On  the  other  hand,  since  the  source  of  contagion  lies 
solely  in  the  discharge  from  the  diseased  membrane, 
and  does  not  exist  in  the  blood  and  in  special  secretions 
of  the  body,  as  in  syphilis,  the  opportunities  for  acquir- 
ing gonorrhoea  outside  the  sexual  act  are  rare.  It  must 
not  be  forgotten,  however,  that  gonorrhoea  may  be  in- 
nocently acquired,  and  that  it  is  possible  for  the  con- 
tagion to  be  conveyed  by  means  of  a  towel,  the  seat 
of  a  public  water-closet,  and  other  media. 

The  Gonococcus. — It  is  now  generally  conceded  that 
the  active  factor  in  the  production  of  gonorrhoea  is 
the  gonococcus  of  Neisser.  Bumm,  Wertheim,  and 
others  have  repeatedly  succeeded  in  cultivating  the 
gonococcus,  and  by  inoculating  the  healthy  urethra 
with  these  cultures  have  produced  an  acute  urethritis 
having  an  incubation  period  of  from  two  to  five  days 
and  a  duration  of  five  or  six  weeks,  the  discharge  con- 
taining gonococci.  In  one  instance  the  twentieth  gen- 
eration of  a  pure  culture  was  thus  successfully  employed. 
These  experiments  seem  to  demonstrate  fully  the  patho- 
genic character  of  this  micro-organism.  It  should  be 
remembered,  however,  that  even  the  normal  urethra 
may  be  inhabited  by  one  or  more  species  of  diplococci, 
which  so  closely  resemble  the  gonococcus  in  all  partic- 
ulars, including  staining  properties,  that  a  positive  diag- 
nosis cannot  always  be  made  without  the  aid  of  culture- 
and  inoculation-tests.  The  gonococcus  is  found  in  the 
purulent  discharge  of  acute  urethritis,  known  as  gonor- 
rhoea;  in  the  muco-purulent  discharge  and  threads 
{tripper  f Men)  of  certain  chronic  and  subacute  forms  of 
urethritis;  in  gonorrhoeal  discharges  from  the  vagina, 
uterus,  conjunctiva,  and  rectum ;  and  a  few  cases  have 
been  recorded  in  which  gonococci  were  found  in  the 
secretion  of  the  mucous  membrane  of  the  mouth  and 


342      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

the  nose.  This  micro-organism  has  also  been  found  in 
joints  affected  with  gonorrhceal  rheumatism,  in  peri-ure- 
thral  folliculitis  and  abscesses,  and  in  suppurating  vulvo- 
vaginal, inguinal,  parotid,  and  other  glands.  It  has  been 
found  (and  demonstrated  by  culture-  and  inoculation- 
tests)  in  the  blood  of  individuals  having  gonorrhoea 
with  metastatic  infection  of  other  organs ;  in  tendo- 
vaginitis, in  endocarditis,  in  pleurisy,  in  acute  diffuse 
peritonitis,  and  in  other  inflammations  developing  during 
the  course  of  gonorrhoea. 

id)  Preparation  and  Examination  of  Specimen. — In 
selecting  gonorrhceal  pus  for  examination  it  is  well  to 
avoid  that  found  at  the  meatus,  as  this  pus  is  more 
liable  to  contain  other  organisms  that  may  render  the 
examination  complicated  and  confusing.  It  is  better  to 
obtain  pus  that  may  be  squeezed  out  of  a  deeper  portion 
of  the  urethra.  A  small  drop  of  this  pus  is  thinly 
spread  on  a  slide  or  a  cover-glass,  by  means  of  a  plat- 
inum wire  or  by  pressing  the  drop  between  two  cover- 
glasses  and  then  slipping  them  apart.  The  thin  film  is 
allowed  to  dry  in  the  air,  and  is  then  fastened  to  the 
glass  by  slowly  passing  it  three  times  through  the  tip 
of  the  flame  of  an  alcohol  lamp  or  a  Bunsen  burner, 
the  pus-covered  side  being  upward.  The  film  is  then 
covered  with  a  few  drops  of  the  staining  fluid,  or  the 
cover-glass  is  floated,  film  side  down,  on  the  liquid. 
The  preparation  should  remain  in  the  stain  from  one  to 
five  minutes,  depending  upon  the  strength  of  the  solu- 
tion, after  which  the  surplus  stain  is  gently  washed  off 
with  a  jet  of  cold  water.  The  specimen  can  now  be 
examined  in  water  or  in  glycerin,  or,  what  is  better,  it 
can  be  dried  carefully  with  soft  blotting-paper  and 
mounted  in  Canada  balsam. 

The  stain  employed  may  be  almost  any  of  the  basic 
aniline  dyes,  as  methyl-blue,  Victoria  blue,  methyl-violet, 
gentian-violet,  or  fuchsin.  These  dyes  may  be  used  in 
aqueous  solutions  of  varying  strength,  but  they  do  not 
keep  well,  and  it  is  best  to  prepare  the  fluid  each  time 


Plate  22. 


Micrococcus  gonorrheas  and  staphylococci.  Aniline  gentian  violet  stain  without 
distaining.  In  the  lower  picture  the  specimen  has  been  partially  decolorized  by 
Gram's  method. 


ACUTE    URETHRITIS.     '  343 

it  is  wanted.  This  may  easily  be  done  by  keeping  on 
hand  a  saturated  alcoholic  solution  of  the  stain,  a  very 
small  quantity  of  which  can  be  added,  drop  by  drop,  to 
a  watch-glassful  of  distilled  water  until  the  latter  is  of 
the  required  strength  and  color.  The  following  is  a 
rapid  and  satisfactory  method :  A  solution  of  methyl- 
blue  is  prepared  by  dropping  a  saturated  alcoholic  solu- 
tion of  the  stain  into  a  watch-glassful  of  distilled  water  or 
into  a  solution  of  potassium  hydrate  (i  :  10,000)  until  the 
liquid  has  a  dark-blue  color.  The  cover-glass,  prepared 
in  accordance  with  the  above  directions,  is  floated  on 
this  liquid,  pus  side  down,  for  from  one  to  two  minutes ; 
it  is  then  taken  out  and  the  surplus  stain  is  washed  off. 
It  may  now  be  placed  at  once,  without  drying,  upon  a 
slide  and  examined,  or  it  may  be  carefully  dried  and 
mounted  on  a  slide  with  Canada  balsam.  In  a  specimen 
thus  prepared  the  gonococci  appear  dark  blue,  while  the 
cells  show  a  very  pale  blue  protoplasm  and  grayish-blue 
nuclei. 

The  gonococci  are  readily  decolorized  by  acids  or 
by  alcohol  as  in  Gram's  method.  In  doubtful  cases  the 
last-named  method  is  claimed  to  be  capable  of  making 
the  diagnosis  a  certainty,  but  it  has  been  pretty  well 
demonstrated  that  a  few  other  diplococci  lose  their  stain 
in  exactly  the  same  manner  as  do  the  gonococci,  and 
that  even  this  test  cannot  always  be  relied  upon.  The 
method  is  as  follows  : 

i.  Prepare  cover-glass  as  above  described. 

2.  Stain  for  from  two  to  five  minutes  in  a  saturated 
solution  of  gentian-violet  in  aniline-water.  (Aniline- 
water  is  prepared  by  adding  5  parts  of  aniline  oil  to  100 
parts  of  water  and  shaking  thoroughly.  The  milky 
fluid  thus  produced  is  filtered  until  it  comes  through 
clear  and  transparent.  To  this  fluid  a  saturated  alco- 
holic solution  of  the  stain  is  added,  drop  by  drop,  until 
the  liquid  loses  its  transparency  and  a  distinct  opales- 
cence results.) 

3.  Place  the  preparation  for  from  one  to  one  and  a 


344      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

half  minutes  in  iodine  solution  (iodine  I  part,  potassium 
iodide  2  parts,  water  300  parts).  In  this  solution  the 
preparation  becomes  quite  black. 

4.  Place  in  alcohol,  and  allow  to  remain  until  no  more 
color  is  extracted. 

5.  Wash  in  distilled  water. 

6.  Stain  for  half  a  minute  in  a  weak  solution  of  Bis- 
marck brown. 

7.  Wash  in  distilled  water. 

8.  Dry  and  mount  in  Canada  balsam. 

The  gonococci  and  a  few  other  diplococci  lose  their 
blue  stain  by  this  method  and  take  a  brown  stain. 
Such  diplococci  as  retain  the  blue  stain  are  not  gono- 
cocci. 

Instead  of  using  a  double  stain,  the  wet  specimen 
may  be  placed  on  a  slide  and  examined,  the  number 
and  position  of  the  diplococci  being  carefully  noted. 
After  decolorizing  in  alcohol  the  preparation  is  mounted 
and  examined.  If  a  large  number  of  diplococci  have  lost 
their  color,  they  are  probably  gonococci. 

For  satisfactory  examination  of  the  preparation,  good 
lenses  having  a  magnifying  power  of  at  least  500  diam- 
eters, and  a  substage  condenser  should  be  employed,  an 
immersion-lens  being  always  desirable  and  in  doubtful 
cases  necessary. 

(b)  Characters. — Each  single  gonococcus  has  a  shape 
much  like  that  of  a  kidney  or  a  coffee-bean ;  but,  like 
other  diplococci,  these  organisms  appear  in  pairs.  Each 
pair  is  thus  made  up  of  two  individuals  so  placed  that 
the  flattened  surfaces  face  each  other,  but  are  separated 
by  a  narrow  space,  which  in  the  stained  specimen  appears 
as  a  clear  (unstained)  line  (PI.  8).  In  the  process  of 
reproduction  each  individual  divides  into  two,  the  divid- 
ing-line being  at  right  angles  to  the  flattened  surface. 
The  result  is  two  pairs  instead  of  one,  and  the  usual 
grouping  of  the  gonococcus  is  explained,  for  it  is  found 
rarely  in  chains,  but  usually  in  clumps  of  four  or  multi- 
ples of  four.     The  micro-organism  is  seen  not  only  be- 


ACUTE    URETHRITIS.  345 

tween  and  upon  the  epithelial  cells  and  pus-cells,  but 
also  within  the  latter.  This  position  in  the  pus-cell  is 
characteristic  of  the  gonococcus,  and  possibly  of  a  few 
other  rarer  forms  of  diplococci,  and  is  determined  by 
observing  that  the  micro-organisms  are  in  focus  at  the 
same  time  with  the  nucleus  and  outlines  of  the  cell,  and 
by  noting  that,  though  a  pus-cell  may  be  filled  with 
gonococci  even  to  its  border,  they  rarely,  if  ever,  project 
beyond  it,  as  would  frequently  be  the  case  if  they  were 
simply  lying  on  the  surface.  A  cell  may  contain  a 
single  group,  or  so  many  as  to  conceal  the  nucleus  or 
finally  to  burst  the  cell-wall,  allowing  the  groups  of 
gonococci  to  escape. 

Until  recently,  culture  of  the  gonococcus  has  been 
unsuccessful  except  on  human  blood-serum.  Wertheim 
used  culture-plates  according  to  Koch's  method,  made 
with  1  part  of  human  blood-serum  and  1  or  2  parts  of 
peptone,  agar,  or  gelatin  solution.  His  cultures  were 
easily  made  and  grew  rapidly.  Other  investigators 
have  employed  with  success  the  serum  of  the  ox,  sheep, 
dog,  and  rabbit,  combined  with  peptone,  agar,  gelatin,  or 
bouillon.  Media  containing  human  serum  give  the  best 
results,  sterile  serum  of  some  sort  being  essential  to  the 
growth  of  the  gonococcus.  The  cultures  grow  slowly, 
and  do  best  on  a  neutral  medium  at  a  temperature  of 
35°  to  37°  C.  Even  under  these  conditions  the  gono- 
coccus usually  dies  in  a  week,  while  at  ordinary  room- 
temperatures  it  is  destroyed  much  earlier.  It  can  survive 
a  temperature  of  400  C.  for  not  more  than  ten  or 
twelve  hours.  Heiman  kept  cultures  alive  eighty-two 
days  in  a  mixture  of  chest-serum  and  nutrient  broth.1 
Using  chest-serum  agar  tubes,  he  succeeded  in  trans- 
planting cultures,  every  five  or  six  days,  25  times. 

{c)  Value  in  Diagnosis. — The  characteristics  of  the 
gonococci  that  distinguish  them  from  other  diplococci 
are  their  shape,  their  grouping  in  fours  or  multiples  of 
four,  their  position  in,  as  well  as  on  and  outside  of,  the 

1  Medical  Record,  Dec.  19,  1896,  and  Jan.  15,  1898. 


346      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

cell,  and  their  staining  properties,  including  especially  the 
readiness  with  which  they  lose  their  stain  when  treated 
with  alcohol.  When  diplococci  possessing  these  charac- 
teristics are  present  in  large  numbers,  there  is  practically 
no  doubt  that  they  are  gonococci ;  but  there  have  been 
found  in  urethral  discharges  diplococci  which  possess 
all  these  characteristics,  but  which  yet  are  not  capable  of 
producing  a  gonorrhoea.  They  are,  however,  not  com- 
mon, are  rarely  present  in  large  numbers,  as  is  the  rule 
with  gonococci,  and  are  usually  associated  with  a  larger 
number  of  other  micro-organisms  common  to  the  urethra. 
They  are  probably  present,  and  liable  to  be  a  source  of 
error  in  diagnosis,  in  about  5  per  cent,  of  all  cases.  Some 
believe  this  percentage  should  be  much  larger.  The 
question  is  plainly  a  most  difficult  one  to  decide,  since 
the  only  method  yet  found  of  making  the  differential 
diagnosis  with  absolute  certainty  lies  in  culture-  and 
inoculation-experiments.  These  methods  must  have  a 
narrow  range  of  application,  since  the  cultivation  of  the 
gonococcus  is  too  laborious  and  difficult  to  be  carried 
out  in  every  case  or  by  anyone  but  an  expert;  while 
inoculation  is  practically  out  of  the  question,  since  man 
is  the  only  animal  yet  clearly  proven  to  be  susceptible 
to  the  disease. 

In  acute  urethritis  the  microscope  is  of  great  value  in 
making  a  diagnosis,  for  the  discovery  of  gonococci  in 
the  discharge  at  once  decides  it  to  be  gonorrhceal  and 
infectious  in  nature  (its  immediate  origin  is  not  neces- 
sarily infectious  ;  see  Bastard  Gonorrhoea),  while  an  acute 
discharge  that  after  repeated  and  thorough  examinations 
on  several  successive  days  fails  to  show  gonococci  is  in 
all  probability  not  gonorrhceal.  In  a  large  class  of  sub- 
acute and  chronic  forms  of  urethritis  the  microscope  ren- 
ders valuable  service,  but  often  by  its  use  alone  the  diag- 
nosis cannot  exactly  be  determined,  and  then  one  must 
rely  upon  culture-tests  and  on  clinical  conditions  and 
experience  to  decide  upon  the  infectious  or  non-infectious 
nature  of  the  case  in  hand. 


ACUTE    URETHRITIS.  347 

id)  The  Gonococcus  Toxines. — Sterilized  toxines  ob- 
tained from  the  bodies  of  dead  gonococci  have  been  in- 
jected into  healthy  urethras  with  the  production  of  acute 
urethritis  clinically  resembling  gonorrhoea,  though  the 
period  of  incubation  was  wanting  and  the  inflammation 
may  run  a  comparatively  short  course.  Injected  into 
the  peritoneal  cavity  of  rabbits,  guinea-pigs,  or  white 
mice,  these  toxines  have  produced  peritonitis  and  inflam- 
matory changes  in  other  organs,  including  the  brain  and 
the  spinal  cord. 

Some  of  the  constitutional  disturbances  occasionally 
seen  in  the  course  of  gonorrhoea  (pains  in  the  joints, 
muscles,  and  tendons ;  erythema,  purpura,  iritis,  peri- 
tonitis, nervous  and  mental  disorders,  etc.)  are  probably 
due  to  absorption  of  these  toxines. 

2.  Psendo-gonorrJioea. — Cases  are  reported  in  which 
micro-organisms  other  than  gonococci  are  responsible 
for  urethritis  closely  resembling  gonorrhoea,  culture-  and 
inoculation-experiments  having  been  made  by  competent 
observers.  These  cases  are  rare,  and  not  yet  well  under- 
stood, but  it  is  necessary  to  bear  in  mind  the  fact  that 
acute  urethritis  of  venereal  origin  may  rarely  be  due  to 
bacteria  other  than  the  gonococcus.  It  has  even  been 
suggested  that  rarely,  under  favorable  conditions  such 
as  prolonged  congestion  of  the  mucous  membrane,  cocci 
normally  found  in  the  urethra  may  take  on  pathogenic 
activity. 

3.  Syphilitic  Urethritis. — During  the  early  stages  of 
syphilis  mucous  patches  may  form  in  the  urethra  and  be 
the  source  of  a  scarcely  noticeable  discharge.  In  a 
patient  under  treatment  for  recognized  syphilis  such  a 
discharge  is  of  little  importance  and  calls  for  no  special 
treatment  or  precautions,  as  it  is  assumed  that  no  physi- 
cian will  allow  a  patient  whom  he  is  treating  for  syphilis 
to  indulge  in  sexual  intercourse.  In  unrecognized  cases 
such  a  discharge  might  prove  a  source  of  infection. 
Further,  a  urethral  chancre  may  furnish  a  discharge 
closely  resembling  that  of  gonorrhoea,  and  this  mistake 


348      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

in  diagnosis  is  frequently  made  as  the  result  of  careless 
examination.  Manipulation  of  the  parts  should  reveal 
the  presence  of  the  sclerosis. 

4.  Urethritis  Tuberculosa. — Primary  tuberculosis  of 
the  urethra  has  been  reported  in  rare  instances.  It 
occasionally  occurs  in  the  form  of  ulceration  in  general- 
ized tuberculosis  of  the  genito-urinary  tract.  The  dis- 
charge from  the  urethra  should  show  tubercle  bacilli. 
The  examination  must  be  conducted  with  great  care, 
and  special  methods  must  be  employed,  otherwise  the 
smegma  bacilli  and  other  micro-organisms  found  in  the 
urethra  and  in  the  urine  will  lead  to  confusion  and  error. 

II.  Non-infectious  Urethritis. — A  mild  or  even  a 
violent  urethritis  may  follow  mechanical  or  chemical 
violence  to  the  urethra.  It  is  difficult  to  decide  how 
often  the  cause  of  these  apparently  frequent  cases  lies 
solely  in  the  urethral  injury,  since  other  causes,  on  care- 
ful investigation,  are  often  disclosed.  The  commonest 
source  of  error  lies  in  the  fact  that  a  urethra  damaged 
by  a  previous  gonorrhoea  may  show  no  evidence  of  its 
diseased  condition  until  it  becomes  the  seat  of  urethritis 
as  the  result  of  an  irritation  that  would  have  no  effect 
upon  a  perfectly  sound  urethra.  Some  individuals  of  a 
strumous  or  gouty  diathesis  seem  prone  to  urethritis  on 
comparatively  slight  provocation,  such  as  the  passage  of 
highly  acrid  urine,  indulgence  in  beer  or  alcohol  in  any 
form,  or  ungratified  sexual  excitement.  In  the  majority 
of  these  cases,  however,  there  is  a  history  of  true 
gonorrhoea  at  some  time  in  the  past.  Somewhere  in 
such  a  urethra  there  probably  has  existed  an  area  of 
congestion  or  thickening  or  a  forming  stricture.  While 
a  diathesis  is  frequently  responsible  for  the  readiness 
with  which  some  men  acquire  the  disease,  and  while  the 
systemic  condition  often  exerts  a  most  important  influ- 
ence upon  the  course  and  duration  of  the  local  process, 
in  the  vast  majority  of  cases  the  production  of  urethral 
inflammation  requires  the  presence  of  an  irritant  acting 
locallv. 


ACUTE    URETHRITIS.  349 

Mechanical  violence  may  produce  an  inflammation  of 
a  urethra  that  has  previously  been  sound.  This  form 
of  urethritis  follows  the  improper  use  of  sounds  and 
other  instruments  by  unskilled  or  careless  operators,  the 
introduction  by  the  patient  of  foreign  bodies  into  the 
urethra  or  the  bladder,  and  occasionally  the  passage  of 
fragments  of  calculi  from  the  bladder.  This  form  of 
urethritis  usually  develops  within  a  few  hours  after  the 
violence  is  done,  and  its  intensity  and  duration  are  in 
direct  proportion  to  the  amount  of  mechanical  damage 
inflicted  upon  the  mucous  membrane.  It  generally  dis- 
appears promptly  on  removing  the  cause,  without  further 
treatment  than  is  necessary  to  keep  the  urine  bland  and 
unirritating  to  the  injured  surface. 

Chemical  violence,  resulting  from  the  use  of  too  strong 
injections,  from  irritating  vaginal  secretions  or  toxines, 
from  the  internal  use  of  cantharides,  and  possibly  from 
too  great  concentration  of  the  urine,  may  produce  ure- 
thritis in  varying  degree  of  severity.  Here,  again,  the 
symptoms  come  on  promptly  without  any  period  of  in- 
cubation, and,  as  a  rule,  the  cause  having  been  removed, 
disappear  rapidly  under  very  simple  treatment. 

With  these  forms  of  urethral  inflammation  should  be 
considered  the  cases  of  urethritis  caused  by  irritating 
vaginal  secretions  and  discharges  in  women  in  whom 
no  trace  of  gonorrhoea  can  be  recognized  on  examina- 
tion. That  some  men  under  favorable  circumstances 
do  thus  acquire  a  urethritis  is  unquestionably  true. 
On  the  other  hand,  a  married  man  who  has  had  no 
previous  disease  of  the  urethra,  who  is  otherwise  well, 
and  who  is  indulging  in  no  sexual  excesses,  rarely 
acquires  a  urethritis  from  his  wife,  even  though  she  have 
a  leucorrhceal  or  menstrual  flux.  Even  the  discharges 
from  a  carcinoma  of  the  uterine  neck  or  from  a  tuber- 
culous ulcer  usually  fail  to  injure  the  urethra  of  the 
husband.  It  would  seem  that  these  discharges  are 
capable  of  causing  urethritis  only  when  there  is  a  pre- 
viously diseased   urethra,  a  strumous  diathesis,  a  debili- 


350      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

tated  condition  of  the  body,  prolonged  sexual  excite- 
ment, excesses  in  coitus,  possibly  following  unusual 
indulgence  at  table  and  in  alcoholic  beverages,  or,  as 
most  frequently  happens,  a  combination  of  several  of  the 
conditions  named. 

Clinical  experience  shows  that  a  woman,  wife  or  mis- 
tress, may  be  incapable  of  giving  urethritis  to  husband 
or  lover,  while  a  stranger  may  promptly  acquire  the 
disease  in  a  single  coitus  with  her.  This  is  cited  as  proof 
of  the  so-called  "  acclimatization  ':  of  which  Ricord  and 
other  writers  speak.  Not  infrequently  a  newly-married 
man  consults  his  physician  for  a  mild  or  even  violent 
urethritis,  in  great  alarm  lest  his  really  innocent  wife  be 
not  pure.  If  his  urethra  was  previously  sound  (in  the 
majority  of  such  cases  the  man  has  had  a  gonorrhoea  at 
some  previous  time),  it  is  probable  that  his  wife  has 
leucorrhcea,  or  both  have  disregarded  the  beginning  or 
the  end  of  the  menstrual  flux,  besides  indulging  to  ex- 
cess, possibly  after  partaking  of  alcoholic  or  other  stimu- 
lating articles  of  food  and  drink.  Such  a  urethritis  sub- 
sides in  a  few  days  under  simple  treatment;  and  if  in  the 
future  their  sexual  relations  are  properly  regulated,  the 
husband  will  in  all  probability  remain  free  from  any 
future  attack. 

It  is  in  this  class  of  cases  that  the  tact  as  well  as  the 
skill  and  judgment  of  the  physician  are  severely  tested. 
He  will  be  asked  innumerable  questions,  and  upon  his 
answers  may  depend  the  honor  of  wife  or  husband  or 
the  integrity  and  future  domestic  relations  of  an  entire 
household.  It  is  far  better  to  let  the  guilty  escape, 
or  to  permit  a  patient  to  think  that  a  successful  im- 
position has  been  practised  upon  his  physician,  than 
falsely  to  accuse  the  innocent.  With  this  end  in  view 
he  will  bear  in  mind  the  following  facts  : 

I.  A  healthy  man  with  a  sound  urethra  rarely  (if  ever) 
acquires  a  urethritis  from  a  healthy  woman,  even  if  he 
indulge  to  excess.  (In  connection  with  this  statement,  it 
must  be  remembered  that  cases  of  urethritis  occur  occa- 


ACUTE    URETHRITIS.  35  I 

sionally  in  which  the  most  skilful  and  careful  investiga- 
tion fails  to  find  any  cause  for  the  disease ;  and  the 
statement  is  made  by  a  few  competent  observers  that  in 
rare  instances  a  man  may  contract  gonorrhoea  from 
sexual  intercourse  with  a  woman  who  has  never  had 
the  disease.) 

2.  A  healthy  man  with  a  sound  urethra  does  not,  as 
a  rule,  acquire  a  urethritis  from  a  woman  with  vaginal 
secretions  or  discharges  which  are  not  gonorrhceal.  To 
this  rule,  however,  clinical  experience  furnishes  some 
undoubted,  and  many  apparent,  exceptions. 

3.  There  are  instances  in  which  a  man  of  strumous, 
gouty,  or  tubercular  diathesis,  or  with  a  debilitated 
general  system,  may  acquire  a  mild  form  of  urethritis 
through  sexual  intercourse  with  a  healthy  woman,  par- 
ticularly if  repeated  coitus  with  her  be  accompanied  by 
other  excesses,  as  at  table.  If  the  woman,  instead  of 
being  healthy,  has  a  leucorrhcea,  urethritis  follows  more 
frequently  and  may  be  severe  in  type. 

4.  There  are  many  men  with  a  slightly  damaged 
urethra,  the  only  evidence  of  which  may  be  a  drop  or 
two  of  muco-purulent  discharge  at  the  meatus  in  the 
morning,  or  the  presence  of  small  threads  of  pus  in  the 
urine,  or,  indeed,  with  no  apparent  symptoms,  who  are 
ready  to  light  up  anew  a  urethritis  as  a  result  of 
any  of  the  causes  above  named.  Slight  disturbances  of 
the  general  economy  (such  as  bronchitis,  constipation, 
or  diarrhoea),  the  excessive  use  of  tobacco,  beer,  or 
alcohol,  violent  exercise,  and  great  fatigue  sometimes 
suffice  without  sexual  excitement  for  such  relapses; 
while  sexual  indulgences  of  any  nature  are  almost  cer- 
tain to  be  followed  by  a  reappearance  of  the  old  trouble. 
These  are  cases  of  so-called  bastard  gonorrhoea.  They 
are  generally  subacute  in  type  from  beginning  to  end,  and 
may  present  no  symptoms,  or  none  other  than  a  slight 
discharge,  with  possibly  moderate  itching  at  the  meatus. 
They  usually  run  a  short  course,  but  they  may  be  pro- 
tracted, and  if  the  irritation  be  sufficiently  violent  they 


352      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

may  present  any  degree  of  inflammation  up  to  that  found 
in  gonorrhoea.  These  cases  are  non-infectious  in  their  im- 
mediate origin  ;  but  if,  as  is  often  true,  gonococci  were 
still  present  in  such  a  damaged  urethra,  they  may  multi- 
ply under  the  added  inflammation,  and  a  true  gonor- 
rhoea, generally  subacute,  may  result. 

5.  A  woman  may  have  a  true  gonorrhoea  which  the 
examining  physician  is  unable  to  detect.  This  is  espe- 
cially true  if  the  disease  be  limited  to  the  urethra,  and 
the  acute  stage,  with  swelling  and  redness  of  the  parts, 
has  passed ;  or,  again,  if  there  be  left  only  a  chronic  and 
subacute  inflammation  of  the  vulvo-vaginal  glands. 
Noeggerath  and  others  have  proved  beyond  dispute 
that  the  Fallopian  tubes,  the  uterus,  and  the  cervix  uteri 
may  be  the  seat  of  a  true  gonorrhceal  inflammation  and 
yet  present  no  evidence  that  can  be  detected  in  a  most 
careful  examination  of  the  external  genitals  and  vagina. 
In  the  face  of  such  evidence  it  is  surprising  that  some 
physicians  are  willing,  after  examining  public  women,  to 
give  them  a  certificate  to  the  effect  that  they  have  no 
venereal  disease.  A  large  proportion  undoubtedly  of 
all  pelvic  diseases  in  women  have  their  origin  in  gonor- 
rhoea. From  coitus  with  a  woman  having  one  of  these 
unrecognized  forms  of  gonorrhoea  some  men  will  escape, 
while  others  will  acquire  the  disease. 

6.  The  non-infectious  forms  of  urethritis  have  no 
period  of  incubation,  as  in  gonorrhoea,  but  promptly  fol- 
low the  operation  of  the  exciting  cause.  They  tend  to 
a  rapid  recovery  upon  the  removal  of  that  cause,  and  are 
usually  mild  in  type  as  compared  with  gonorrhoea, 
though  they  may  exhibit  a  severe  grade  of  inflamma- 
tion, and,  rarely,  be  protracted  in  course  and  clinically 
indistinguishable  from  true  gonorrhoea.  No  gonococci 
can  be  demonstrated  either  with  the  microscope  or  in 
cultures. 

Symptoms. — As  a  matter  of  convenience  in  descrip- 
tion, the  course  of  gonorrhoea  is  here  studied  in  suc- 
cessive stages ;   these  stages  are  not,  however,  always 


ACUTE    URETHRITIS.  353 

definite   in   duration   or   sharply  defined    one    from  the 
other. 

1.  Stage  of  Incubation. — At  the  time  of  infection  the 
virus  is  conveyed  to  the  sound  membrane  in  a  very 
small  quantity — too  small  to  cause  immediately  a  per- 
ceptible irritation — and  it  is  not  until  the  gonococci  have 
developed  and  multiplied  that  they  or  their  products,  or 
both,  produce  a  visible  disturbance  in  their  new  habitat. 
The  time  required  for  this  development  varies  from  one 
to  fourteen  days,  but  in  fully  two-thirds  of  all  cases  it  is 
from  five  to  seven  days.1  This  wide  variation  is  undoubt- 
edly due  in  part  to  the  degree  of  virulence  of  the  par- 
ticular virus,  to  the  character  of  the  soil  upon  which 
it  is  implanted,  to  the  number  of  gonococci  thus  trans- 
ferred, and  to  other  circumstances  attending  its  inocu- 
lation ;  but  the  characteristics  of  the  individual  also 
play  an  important  part.  A  highly  sensitive  man,  and,  in 
particular,  one  who  is  fearing  and  carefully  watching  for 
the  result  of  an  exposure,  will  detect  the  earliest  slight 
symptoms,  which  would  pass  unnoticed  by  the  average 
man ;  while  among  the  careless  and  uncleanly  the  dis- 
charge may  become  pronounced  before  attention  is 
directed  to  it. 

When  unmistakable  symptoms  appear  before  the 
third  day,  careful  inquiry  will  usually  elicit  a  history  of 
more  or  less  recent  gonorrhoea  from  which  the  patient 
has  really  never  fully  recovered,  though  he  may  have 
supposed  himself  well.  The  case  is  then  one  of  bastard 
gonorrhoea.  In  simple  urethritis  the  period  of  incuba- 
tion is  wanting  or  is  of  only  a  few  hours'  duration. 

2.  Beginning  or  Prodromal  Stage. — The  stage  of  in- 
cubation may  be  said  to  end,  and  the  prodromal  stage 
to  begin,  when  the  patient  first  notices,  especially  on 
urinating,  a  slight  teasing,  pricking,  tickling,  or  uneasy 
sensation  at  the  meatus  urinarius.  On  examination 
the   lips  of  the  meatus  may  be  slightly  red,  or,  if  the 

1  Cases  are  reported  in  which  the  incubation  period  was  twenty  (in  one 
case  thirty)  days. 

23 


354      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

patient  has  not  urinated  for  some  time,  they  may  be 
slightly  stuck  together  by  a  drop  of  viscid  mucus  re- 
sembling in  appearance  the  white  of  an  egg.  Without 
the  aid  of  the  microscope  this  fluid  cannot  be  distin- 
guished from  the  mucus  secreted  by  the  urethra  and 
prostate  during  sexual  excitement ;  the  redness  is  no 
more  than  could  come  from  accidental  chafing  or  fric- 
tion of  the  parts  with  the  clothing ;  and  in  the  majority 
of  cases  the  diagnosis  must  be  withheld  for  a  day  or  two 
until  the  beginning  of  the  active  or  increasing  stage. 
Under  the  microscope  the  discharge  is  seen  to  be  made 
up  of  mucus  containing  more  or  less  columnar  or  fiat 
epithelium.  In  some  instances  gonococci  can  be  seen 
upon  the  surface  of  the  epithelial  cells,  and  an  early 
diagnosis  can  thus  be  made.  Often,  however,  the  gono- 
cocci are  present  in  such  small  numbers  that  they 
are  difficult  to  find  and  to  demonstrate  satisfactorily. 
Failure  to  find  them  will  not  warrant  the  exclusion  of 
gonorrhoea  until  several  slides  have  been  examined  on 
successive  days,  and  in  the  meantime  the  inflammation 
progresses  to  the  next  stage. 

3.  Increasing  Stage. — The  itching  or  other  sensation 
at  the  meatus  now  becomes  one  of  slight  burning  or 
smarting  on  urinating,  and  gradually  increases  in  se- 
verity. The  secretion  increases  in  quantity  until  it  is 
sufficient  slightly  to  stain  the  linen,  and  becomes  thicker 
and  opaque.  The  microscope  shows  pus-cells  and  gono- 
cocci, which  increase,  while  the  epithelial  cells  rap- 
idly decrease,  in  number  each  day.  The  lips  of  the 
meatus  become  more  sensitive,  red,  swollen,  and  everted, 
and  as  the  disease  progresses  the  entire  glans  and  pre- 
puce may  gradually  share  in  the  inflammatory  process. 
In  an  untreated  case  these  symptoms  gradually  increase 
in  severity  for  from  eight  to  fifteen  days  after  the  begin- 
ning of  this  stage. 

The  discharge  becomes  purulent,  at  first  milky,  and 
then  thicker  and  creamy  in  consistence.  It  grows 
darker  in  color  until  of  a  greenish  yellow,  the  tint  being 


ACUTE    URETHRITIS.  355 

due  to  the  presence  of  a  small  amount  of  blood.  If  the 
mucous  membrane  becomes  cracked,  the  blood  may 
appear  in  the  discharge  in  streaks,  or  there  may  be  con- 
siderable hemorrhage.  The  discharge  is  often  exces- 
sive ;  sometimes  several  drops  appear  at  the  meatus,  and 
fall,  if  not  wiped  away,  during  the  few  moments  occupied 
by  the  physician  in  examining  the  patient,  to  whom  this 
constant  dripping  is  a  source  of  inconvenience  and  fre- 
quently of  great  mental  distress. 

The  pain  on  urinating,  which  at  first  was  slight, 
increases  and  may  become  agonizing  in  severity,  caus- 
ing the  patient  to  retain  his  urine  as  long  as  possible. 
Often,  when  he  does  urinate  he  is  afraid  to  permit  the 
urine  to  pass  in  a  full  stream,  since  this  would  stretch 
the  swollen  and  sensitive  mucous  membrane  and  thus 
cause  more  pain.  Then,  too,  the  calibre  of  the  urethra 
is  smaller  than  normal,  in  consequence  of  the  thicken- 
ing of  its  mucous  membrane,  and  the  stream  of  urine 
is  thus  diminished  in  diameter,  divided,  twisted,  forked, 
and  frequently  interrupted.  The  urine  may  come  only 
in  drops,  or  there  may  be  complete  retention.  This 
last  is  rare  except  in  the  case  of  an  individual  who 
had  a  stricture  previous  to  his  present  attack.  The 
pain,  at  first  located  near  the  meatus,  now  extends  along 
the  entire  pendulous  portion  of  the  urethra,  though  it 
is  usually  most  intense  near  the  meatus,  the  fossa  na- 
vicularis,  or  at  the  root  of  the  penis.  It  is  not  limited  to 
the  time  of  urination,  but  is  more  or  less  constant,  and 
it  often  radiates  from  the  penis  to  the  testicles,  cord, 
perineum,  groins,  thighs,  and  back.  There  is  also  in 
these  regions  a  feeling  of  weight  and  tension. 

During  this  stage  there  is  usually  more  or  less  sexual 
irritation,  with  painful  erections  and  with  seminal  emis- 
sions which  may  be  mixed  with  blood.  The  inflamed 
and  thickened  mucous  membrane  of  the  urethra  is  not 
capable  of  distention,  and,  moreover,  the  inflammation 
may  extend  to  a  part  or  all  of  the  corpus  spongiosum, 
filling  up  the  meshes  of  its  structure  with  plastic  lymph 


356      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

and  rendering  them  also  incapable  of  distending  to  meet 
the  demands  of  the  elongated  corpora  cavernosa  during 
erection.  These  two  bodies  above,  which  usually  escape 
the  inflammation,  become  distended  with  blood,  elon- 
gated, and  pull  upon  the  inflamed  and  sensitive  but  now 
inelastic  tissues  of  the  urethra  and  the  corpus  spongi- 
osum. The  result  is  a  torturing  pain  and  a  curving  of 
the  penis  forward  and  downward,  forming  a  bow  of 
which  the  urethra  is  the  taut  string.  At  such  a  time 
the  lips  of  the  meatus  may  be  seen  drawn  in,  forming 
a  funnel.  This  is  chordee,  and  is  especially  apt  to  come 
on  at  night  under  the  influence  of  the  warmth  of  the 
bed.  The  sufferer  will  rise  and  by  the  application  of 
heat  or  cold  reduce  the  chordee,  only  to  have  it  return 
when  again  he  is  warmed  in  bed.  In  this  manner  his 
rest  at  night  is  broken.  Sometimes,  becoming  desper- 
ate, he  attempts  forcibly  to  "break"  the  cord  by  resting 
the  penis  on  some  hard  substance  and  striking  it  with 
his  fist.  The  usual  result  is  sudden  hemorrhage,  and 
later  the  formation  of  traumatic  stricture. 

The  inflammation,  at  first  limited  to  the  lips  of  the 
meatus,  extends  until  the  entire  glans  is  swollen,  turgid, 
red,  or  even  highly  inflamed  and  excoriated.  The  pre- 
puce becomes  cedematous,  and  balanitis  of  mild  or 
severe  grade  may  be  present.  As  a  result  phimosis 
and  paraphimosis  are  frequent  complications.  The 
lymphatics  of  the  penis  may  become  inflamed,  and 
may  be  felt  as  hard  cords,  usually  about  the  size  of  a 
knitting-needle,  but  at  times  much  larger,  extending  to 
the  symphysis  pubis.  They  are  usually  painful  and  sen- 
sitive, their  course  being  marked  by  a  red  line.  Occa- 
sionally these  firm  cords  act  upon  the  erect  penis  as  the 
urethra  does  in  chordee,  producing  a  curvature  in  vari- 
ous directions.  The  inflammation  of  the  lymphatics 
usually  readily  terminates  in  resolution  and  does  not 
often  call  for  serious  consideration.  The  inguinal  glands 
may  be  involved  and  become  slightly  swollen  and 
tender,  but  suppuration  is  rare. 


ACUTE    URETHRITIS.  357 

4.  Stationary  Stage. — With  good  hygienic  manage- 
ment the  inflammation,  after  reaching  its  height,  remains 
stationary  for  about  a  week,  though  under  unfavorable 
surroundings  and  in  unhealthy  individuals  this  stage 
may  be  protracted  for  several  weeks.  Usually,  at  the 
end  of  the  third  week  from  the  first  appearance  of  the 
discharge  the  stage  of  decline  begins. 

5.  Stage  of  Decline. — During  this  stage  the  symp- 
toms gradually  subside;  the  discharge  grows  less,  until, 
at  about  the  end  of  the  fourth  or  fifth  week,  it  is  again 
represented  by  only  a  few  drops  daily  of  a  sticky 
mucous  discharge,  which  in  the  course  of  another  week 
or  two  disappears  entirely,  and  the  patient  is  well  except 
for  a  sensitive  condition  of  the  urethra  that  will  prob- 
ably persist  for  some  weeks. 

The  foregoing  description  applies  to  an  untreated, 
uncomplicated  case  of  gonorrhoea  in  an  otherwise 
healthy  man,  living  under  good  hygienic  conditions, 
who  is  not  subjected  to  too  much  physical  exertion,  who 
is  indulging  in  no  excesses  in  the  way  of  food,  drink,  or 
tobacco,  and  who  avoids  all  sexual  excitement.  In  such 
a  case  the  duration  of  gonorrhoea  which  terminates  favor- 
ably is  usually  six  or  eight  weeks  ;  but  even  in  uncom- 
plicated and  typical  cases  the  disease  varies  greatly  in  its 
duration  and  intensity,  and  shows  a  strong  tendency  to 
persist  in  a  chronic  form.  The  increasing  stage  of  the 
disease,  usually  about  twenty  days,  may  be  prolonged 
for  weeks ;  or  after  the  inflammation  has  reached  its 
height  it  may  remain  stationary  for  some  weeks  instead 
of  a  few  days.  Most  frequently  protracted,  however, 
is  the  stage  of  decline.  Instead  of  steadily  and  uni- 
formly progressing  to  recovery,  the  disease  may  improve 
for  a  time  and  then  remain  unchanged,  or  the  process 
may  be  lighted  up  afresh  and  recovery  be  delayed  by  a 
series  of  relapses. 

Frequently,  some  indiscretion  on  the  part  of  the  patient 
after  he  considers  himself  practically  well  causes  a  return 
of  acute  symptoms,  though  they  are  rarely  so  severe  in 


358      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

type  as  in  the  early  stages  of  the  disease.  Each  suc- 
ceeding relapse  is  usually  less  severe  than  that  preced- 
ing, but  the  prolongation  of  the  inflammation  increases 
the  natural  tendency  of  the  disease  to  localize  itself  in 
a  chronic  form  in  the  fossa  navicularis,  in  the  region  of 
the  bulb,  or  in  any  part  of  the  urethra  that  has  hap- 
pened to  suffer  most  severely  during  the  acute  process. 
Thus  are  left  circumscribed  areas  of  granulation  or 
thickening  of  tissue  which  may  result  in  chronic  gleet 
and  may  finally  go  on  to  the  formation  of  stricture. 

The  disease  varies  as  widely  in  the  intensity  of  its 
symptoms  as  in  its  duration.  In  very  mild  cases  there 
may  be,  from  beginning  to  end,  almost  no  pain  or  other 
evidence  of  inflammation  aside  from  the  discharge,  which 
may  nevertheless  be  profuse.  In  the  majority  of  skil- 
fully treated  cases  of  gonorrhoea  the  other  symptoms 
rapidly  subside,  and  the  discharge  remains  the  chief,  if  not 
the  sole,  source  of  trouble  to  the  patient.  In  very  severe 
cases,  on  the  contrary,  the  constant  and  severe  pain,  in- 
creased by  great  sexual  irritation,  chordee,  bloody  semi- 
nal emissions,  hemorrhages,  and  discomfort  in  urination, 
together  with  mental  distress  and  loss  of  sleep,  tell  forci- 
bly on  the  general  health.  If  the  disease  extends  to  the 
posterior  urethra — as  it  does  in  many  cases — one  or  more 
serious  complications  (posterior  urethritis,  epididymitis, 
prostatitis,  vesiculitis,  or  cystitis)  may  result. 

The  causes  of  this  wide  variation  in  the  course  of 
gonorrhoea  lie  partly  in  the  peculiarities  of  the  individual, 
but  largely  in  his  hygenic  surroundings.  Syphilis,  tuber- 
culosis, scrofula,  gout,  malnutrition  from  any  cause,  and 
great  fatigue,  all  tend  to  retard  the  recovery  of  the  dis- 
ease ;  while  sexual  excitement  of  any  kind,  the  use  of 
tobacco,  alcohol,  or  stimulating  foods,  and  too  much  or 
too  vigorous  physical  exertion,  as  in  walking,  dancing, 
or  riding,  all  tend  to  prolong  and  increase  the  severity 
of  the  inflammation.  If  a  patient  with  gonorrhoea  ac- 
quire a  febrile  disease,  his  urethral  symptoms  usually 
subside  while  the  fever  lasts,  but  return  with  the  disap- 


ACUTE    URETHRITIS.  359 

pearance  of  the  fever.  Indigestion,  constipation  or  diar- 
rhoea, and  other  minor  disturbances  of  the  general  health, 
as  a  common  cold,  usually  delay  and  aggravate  the 
course  of  gonorrhoea.  The  first  attack,  particularly  of 
a  young  man,  is,  as  a  rule,  the  most  severe,  but  it  is  also 
most  likely  to  terminate  in  complete  recovery.  Succes- 
sive attacks  may  be  less  severe,  but  they  are  generally 
more  protracted  and  obstinate  and  exhibit  greater  ten- 
dency to  become  chronic. 

Constitutional  symptoms  are  wanting  usually,  except 
as  they  result  from  loss  of  sleep  and  from  mental  dis- 
tress. The  latter  is  often  excessive,  rendering  a  man 
totally  unfit  for  his  usual  vocation.  Occasionally  a  mild 
or  even  a  severe  systemic  toxaemia  produces  pains  in  the 
joints,  tendons,  or  muscles ;  or  is  manifested  in  the 
form  of  usually  mild  peritonitis,  endocarditis,  pleurisy, 
and  nervous  disturbances ;  or  is  responsible  for  the  rare 
cases  of  erythema  and  purpura  seen  during  the  course 
of  gonorrhoea.  Metastatic  infection  may  result  in  the 
more  serious  complications  already  mentioned,  and  which 
are  described  in  succeeding  chapters. 

The  symptoms  of  non-infections  urethritis  may  be 
nothing  more  than  a  few  drops  of  muco-pus,  possibly 
so  small  in  amount  as  to  cause  no  more  than  a  slight 
gluing  together  of  the  lips  of  the  meatus.  Men  of 
strumous  or  lithaemic  diathesis,  and  particularly  those 
having  a  slightly  damaged  urethra,  present  these  sub- 
acute cases  after  excesses  of  any  kind.  From  this  low 
type  of  inflammation  there  are  all  gradations  to  that 
described  as  the  acute  stage  of  gonorrhoea,  though 
severe  cases  are  rare,  and  are  usually  the  immediate  re- 
sult of  chemical  or  mechanical  violence  to  the  urethra. 
Too  frequently  they  result  from  local  treatment  for  imag- 
inary ills.  The  duration  of  acute  symptoms  is  brief, 
varying  from  a  few  hours  to  a  few  days. 

Bastard gonorrlicea  is  usually  subacute,  presenting  the 
symptoms  found  in  the  declining  stage  of  gonorrhoea. 
There  is,  furthermore,  a  history  of  frequent   recurrence 


360      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

from  slight  causes  that  would  not  affect  a  normal 
urethra.  The  discharge  may  show  few  or  no  gonococci, 
though  other  diplococci  are  often  present.  Frequently 
no  micro-organisms  can  be  demonstrated.  Under  simple 
treatment  the  urethra  thus  affected  generally  returns  to 
its  former  condition  in  a  few  days.  If,  under  the  in- 
fluence of  the  irritation,  the  gonococci  which  may  have 
been  lying  quiescent  in  the  urethra  multiply  sufficiently, 
the  inflammation  may  be  more  acute  in  type,  slow  in 
reduction,  and  in  no  way  different  from  a  mild  attack  of 
gonorrhoea,  except  that  the  inflammation  reaches  its 
height  more  rapidly  and  the  period  of  incubation  is  brief. 
Pathology. — Our  knowledge  of  the  pathology  of 
gonorrhoea  is  very  imperfect,  owing  to  the  fact  that  in 
this  disease  few  opportunities  are  afforded  for  making 
histological  and  post-mortem  examinations.  Finger  gives 
the  following  description  of  the  gross  appearances : 
"  Urethritis  constitutes  an  inflammation  of  the  mucous 
membrane  and  submucous  tissue,  with  all  its  character- 
istics, such  as  redness  and  swelling  and  secretion  of  a 
mucous,  muco-purulent,  or  purulent  discharge.  The 
intensity  of  the  inflammation  will  vary,  and  hence  the 
mucous  membrane  presents  different  appearances.  Some- 
times the  swelling  will  be  slight  and  the  injection  den- 
dritic ;  .sometimes  the  redness  and  swelling  will  be  very 
marked.  The  glands  and  follicles  always  appear  to  be 
affected  early  and  intensely.  They  become  swollen ; 
their  openings  gape  in  the  shape  of  a  funnel.  The  in- 
flammation also  extends  to  the  lumen  of  the  glands,  and 
even  the  parenchyma  takes  part  in  the  inflammation  and 
in  the  production  of  morbid  secretion.  If  the  lumen  of 
the  gland  or  follicle  is  now  occluded  by  a  firm  plug  of 
mucus  or  pus,  retention  of  pus  and  the  formation  of 
cysts  result.  Desquamation  of  the  epithelium  and  super- 
ficial losses  of  substance  also  take  place  at  the  mouth  of 
the  follicle,  and  if  the  process  is  severe  may  lead  to 
small  ulcerations  (clap-ulcers).  Deeper  ulcers  may  also 
develop,  perhaps,  from  the  rupture  of  one  or  more  cysts 


ACUTE    URETHRITIS.  36 1 

due  to  occlusion  of  the  gland-openings.  This  early  and 
intense  implication  of  the  glands  explains  the  obstinacy 
of  clap  and  its  tendency  to  relapse.  The  latter  is  due  to 
the  persistence  of  the  process,  which  has  died  out  on  the 
surface,  in  one  or  more  glands,  where  the  virus  increases 
and  may  then  be  discharged  upon  the  surface ;  perhaps 
because  the  secretion  of  the  virus  is  increased  by  local 
and  general  irritating  influences,  such  as  coitus  and  ex- 
cesses in  Baccho." 

The  histological  changes  have  been  studied  chiefly  in 
gonorrhceal  inflammation  of  the  conjunctiva  and  the  rec- 
tum ;  but,  reasoning  from  analogy,  it  is  probable  that  soon 
after  a  secretion  containing  gonococci  is  deposited  upon 
the  mucous  membrane  of  the  urethra,  these  micro-organ- 
isms multiply  and  find  their  way  between  the  superficial 
cells  to  the  deeper  epithelial  elements  and  to  the  upper 
layers  of  the  connective  tissue.  Here  they  proliferate 
and,  probably  through  the  influence  of  their  toxines, 
cause  an  irritation  which  produces  an  active  hyperaemia 
with  dilatation  of  the  vessels  and  exudation  of  serum. 
The  resulting  swelling  of  the  mucous  membrane  dimin- 
ishes the  lumen  of  the  urethra,  and  may  even  occlude  it. 
The  hyperaemia  rapidly  becomes  an  inflammation,  with 
the  appearance  of  large  numbers  of  leucocytes  and 
round  cells  in  the  tissues,  and  the  destruction  of  much 
of  the  epithelium.  The  leucocytes  make  their  way 
to  the  surface,  carrying  with  them  large  numbers  of 
gonococci.  This  they  continue  to  do  throughout  the 
entire  course  of  the  disease,  until  the  invading  micro- 
organisms are  entirely  removed.  The  round-cell  infil- 
tration and  other  evidences  of  inflammation  now  disap- 
pear, new  epithelial  cells  take  the  place  of  those  that  have 
been  destroyed  and  exfoliated,  and  the  disease  is  at  an  end. 
The  process  begins  in  the  anterior  portion  of  the  urethra 
and  rapidly  travels  back  as  far  the  bulb,  and  in  many 
cases  goes  further  and  involves  the  membranous  and 
prostatic  divisions  of  the  urethra. 

It  is  not  usual  for  the  mucous  membrane  in  all  parts 


362      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

of  the  urethra  to  recover  at  once.  The  inflammation 
and  the  gonococci  may  linger  for  months  or  years  in 
one  or  more  glands,  in  the  fossa  navicularis,  in  the  cul- 
de-sac  of  the  bulb,  in  the  prostatic  follicles,  or  in  some 
other  portion  that  has  happened  to  suffer  more  severely 
than  others. 

Diagnosis. — Examination  of  the  Patient. — No  physi- 
cian will  succeed  in  the  treatment  of  venereal  diseases 
who  does  not  habitually  make  thorough  and  careful 
examinations.  With  this  end  in  view  he  should  obtain 
a  fairly  good  knowledge  of  his  patient's  general  condi- 
tion and  history — the  more  complete  the  better — before 
coming  to  the  consideration  of  the  local  trouble.  Other- 
wise this  information  will  be  acquired,  if  at  all,  in  unsat- 
isfactory and  detached  fragments,  and  quite  probably  so 
late  as  to  necessitate  changes  in  instructions  and  treat- 
ment already  given.  This  not  only  is  a  waste  of  time, 
but  it  leads  to  confusion  in  the  mind  of  the  patient  and 
does  not  increase  his  confidence  in  his  physician.  Be- 
sides learning  the  general  state  of  the  health,  the  physi- 
cian should  be  informed  regarding  the  habits  of  eating, 
drinking,  tobacco-usage,  sleep,  exercise,  and  all  hygienic 
surroundings.  Exact  history  of  any  previous  venereal 
diseases  should  be  obtained. 

In  the  local  examination  thoroughness  is  imperative. 
No  intelligent  practitioner  or  student  of  medicine  will 
order  treatment  for  a  man  on  the  strength  of  the  state- 
ment that  he  has  nothing  but  a  discharge  or  a  "  run- 
ning" from  the  urethra.  Nor  is  it  sufficient  merely  to 
look  at  the  discharge.  The  clothing  should  be  removed, 
and  in  the  majority  of  cases  the  fingers  of  the  examiner 
should  first  seek  the  inguinal  region.  If  he  finds  indu- 
rated, insensitive  glands  on  one  or  both  sides,  he  will 
search  for  the  initial  lesion  of  syphilis,  which  he  may 
find  in  the  form  of  a  urethral  chancre  or  of  a  sclerosis  so 
trifling  that  it  would  pass  unnoticed  but  for  the  informa- 
tion obtained  by  the  fingers  in  the  groin.  If  he  find  a 
single  gland  enlarged  and  sensitive,  he  will  suspect  the 


ACUTE    URETHRITIS.  363 

• 

presence  of  chancroid,  of  a  lymphangitis,  or  of  some 
other  complication  not  frequent  in  gonorrhoea.  The 
fingers  will  next  explore  the  testicles,  where  the  presence 
of  indurated  nodules  in  the  epididymis  may  tell  of  pre- 
vious attacks  of  gonorrhoea  or  of  syphilis  which  have 
been  denied  by  the  patient  and  which  call  for  consid- 
eration during  the  treatment  of  the  present  disorder. 

Such  an  examination  of  the  groins  and  testicles,  if 
made  at  the  outset,  requires  but  a  few  seconds,  but  if  left 
until  the  fingers  are  soiled — as  they  are  quite  liable  to  be 
— in  the  examination  of  the  penis,  these  regions  may  be 
neglected.  The  discharge  has  led  the  examiner  to  make 
a  diagnosis  of  gonorrhoea  or  urethritis ;  the  patient  com- 
plains of  no  pain  in  the  groins  or  in  the  testicles,  and 
their  exploration  calls  for  the  time  and  trouble  involved 
in  an  extra  washing  of  the  hands.  An  initial  sclerosis, 
acquired  at  the  same  time  with  the  gonorrhoea  or  inde- 
pendently of  it,  may  thus  be  overlooked,  or  the  patient 
may  return  in  a  few  days  with  a  violent  epididymitis 
which  might  have  been  prevented  had  the  evidence  of 
former  attacks  been  noted  and  proper  precautions  been 
taken.  If  the  prepuce  be  long  or  in  a  state  of  phimosis, 
the  physician  will  make  every  effort — cleansing  the  parts, 
if  necessary — to  determine  that  the  discharge  comes  from 
the  urethra,  and  not  solely  from  the  preputial  sac  affected 
with  balanitis ;  it  may  come  from  both.  He  will  also, 
by  manipulating  the  parts,  satisfy  himself,  as  far  as  pos- 
sible, regarding  the  nature  of  any  other  complications 
that  may  be  present. 

Differential  Diagnosis. — Pseudo-gonorrhoea,  urethritis 
tuberculosa,  and  syphilitic  urethritis,  are  rare  and  do  not 
often  call  for  consideration  in  the  diagnosis,  yet  their 
possible  existence  should  never  be  forgotten.  The 
common  forms  of  urethral  inflammation  are  gonorrhoea, 
bastard  gonorrhoea,  and  simple  urethritis.  The  first  is 
the  most  common,  constituting  a  large  majority  of  all 
cases ;  the  second  is  of  frequent  occurrence ;  while  non- 
infectious urethritis  pure  and  simple,  occurring  in  a  man 


364       SYPHILIS  AND    THE  VENEREAL  DISEASES. 

whose  urethra  was  previously  sound,  is  unusual.  It  is 
evident  that  the  diagnosis  between  bastard  gonorrhoea 
and  simple  urethritis  will  often  be  made  with  great 
difficulty.  If  repeated  examinations  fail  to  find  gono- 
cocci  in  the  discharge,  the  diagnosis  must  rest  upon  the 
history  of  the  patient  and  upon  culture-tests.  If  he  has 
had  former  urethral  discharges,  it  is  safe  to  assume  that 
his  urethra  had  never  fully  recovered  from  the  earlier 
attacks.  In  these  cases  an  accurate  diagnosis,  so  far  as 
the  immediate  treatment  is  concerned,  is  not  essentia^ 
for  in  either  case  the  discharge  usually  subsides  in  a 
few  days  under  simple  treatment ;  the  diagnosis,  how- 
ever, is  of  importance  in  the  matter  of  prognosis  and 
in  determining  the  proper  course  to  be  pursued  in  the 
future. 

The  average  patient  can  with  difficulty  await  the  con- 
clusion of  the  examination  before  asking  to  be  informed 
definitely  if  he  has  true  gonorrhoea  or  if  his  discharge  re- 
sults from  what  is  popularly  known  as  "a  strain"  or  from 
contact  with  innocent  vaginal  discharges.  In  almost  the 
same  breath  he  will  probably  ask  how  long  a  time  is  re- 
quired for  "  curing "  him.  These  questions  frequently 
call  for  the  exercise  of  much  tact,  good  judgment,  and 
good  sense  on  the  part  of  the  physician.  The  man  who 
indulges  in  illegitimate  sexual  relations  with  a  mistress 
or  with  a  woman  generally  supposed  to  be  respectable  is 
loath  to  believe  that  he  is  infected.  He  is  often  positive 
in  his  declarations  that  he  has  not  been  exposed  to 
a  venereal  disease.  Egotism  and  ignorance  give  him 
faith  in  a  woman  he  personally  knows  to  be  immoral. 
The  man,  further,  who  indulges  in  promiscuous  sexual 
relations,  relying  for  his  safety  upon  artificial  methods 
and  devices  for  avoiding  disease,  is  slow  to  realize  that 
his  precautions  have  failed  to  protect  him.  Such 
measures  are  certain  to  fail  sooner  or  later. 

On  the  contrary,  the  young  practitioner  is  inclined  to 
be  too  incredulous  regarding  urethral  discharges  de- 
clared   to    have    been   acquired    innocently,   and    rarely 


ACUTE    URETHRITIS. 


365 


properly  appreciates  the  fact  that  a  large  proportion 
(possibly  one-third)  of  the  seemingly  acute  and  subacute 
cases  are  in  reality  exacerbations,  wrought  by  some  of 
the  causes  already  discussed,  of  a  pre-existing  chronic 
disease.  While  in  the  majority  of  cases  the  diagnosis 
may  be  made  with  sufficient  precision  for  all  practical 
purposes  on  the  first  examination,  especially  if  the  micro- 
scope 'be  used,  there  are  times  when  the  prudent  physi- 
cian will  postpone  his  decision  for  a  few  days,  and  will 
consider  carefully  all  the  evidence  in  the  case  as  well  as 
the  individuality  and  surroundings  of  his  patient  before 
answering  the  questions  put  to  him.  He  will  remember 
that  the  last  possible  source  of  error  in  any  case  can- 
not be  eliminated  without  culture-  and  inoculation-tests, 
and  that  some  competent  observers  believe  it  possible 
for  a  man  or  woman  to  acquire  gonorrhoea  from  sexual 
congress  with  one  of  the  opposite  sex  who  has  never 
had  the  disease.  The  aim  of  the  physician  in  all  cases 
should  be  to  relieve  the  suffering  and  to  protect  the 
innocent. 

The  diagnosis  practically  lies  between  gonorrhoea,  bas- 
tard gonorrhoea,  and  a  simple  urethritis.  Their  causes, 
characteristics,  and  symptoms  need  but  brief  review  here. 
For  convenience  they  are  set  forth  in  tabular  form. 


Gonorrhoea. 

History  of  former  attacks 
not  necessary. 

The  patient's  general  con- 
dition has  no  bearing  on 
the  origin  of  the  disease, 
but  may  exert  a  marked 
influence  on  its  course. 

Urethra  may  have  been 
sound  at  the  time  of  in- 
fection. 


Bastard  Gonorrhoea. 

The  patient  has  had  former 
attacks. 

Enfeebled  constitution  is 
often  a  factor  in  the  pro- 
duction of  the  disease, 
and  frequently  exerts  a 
decided  influence  on  its 
course. 

Damaged  condition  of  ure- 
thra necessary.  Gener- 
ally evidenced  by  gluing 
of  lips  of  meatus  in  the 
morning,  or  by  shreds  in 
the  urine.  Patient  may 
have  seen  no  evidence  of 
disease  for  months,  and 
believed  himself  well. 


Non-  infectious  Ureth  ritis . 

History  of  former  attacks 
not  necessary. 

Enfeebled  constitution  is 
sometimes  the  chief  fac- 
tor in  the  production  of 
the  disease,  and  may  even 
be  the  sole  cause  of  its 
continuance. 

Damaged  condition  of  ure- 
thra not  necessary,  but 
probably  present  in  many 
cases. 


366      SYPHILIS  AND    THE  VENEREAL   DISEASES. 


Gonorrhoea. 

Cause  of  disease  lies  solely 
in  exposure  to  a  gonor- 
rhoea! discharge. 


Period  of  incubation 
ranges  from  one  to  four- 
teen days,  rarely  less 
than  three,  and  usually 
from  five  to  seven. 

Begins  with  slight  symp- 
toms, which  gradually 
increase  in  severity  for 
from  ten  to  fourteen 
days,  when  the  inflam- 
mation is  usually  of  a 
very  high  grade. 

Duration  is  usually  from 
six  to  eight  weeks. 
Acute  stage  lasts  three 
or  four  weeks. 

Discharge  contains  gono- 
cocci   in   large    number. 


Bastard  Gonorrhoea.      Non-infections  Urethritis. 


Immediate  cause  usually 
found  in  sexual  indul- 
gence, with  or  without 
other  excesses.  Occa- 
sionally other  excesses 
are  alone  sufficient. 


Period  of  incubation  usu- 
ally one  or  two  days. 


Usually  subacute  through- 
out. When  more  acute, 
the  symptoms  increase  in 
severity  more  rapidly, 
but  rarely  become  so  se- 
vere as  in  gonorrhoea. 

Duration  very  indefinite — 
perhaps  one  or  many 
weeks.  Acute  stage  usu- 
ally lasts  a  week  or  ten 
days. 

Gonococci  usually  present 
in  small  number. 


Cause  found  in  direct  me- 
chanical or  chemical  vio- 
lence to  the  urethra,  often 
the  result  of  too  ener- 
getic treatment.  In  the 
cachectic  and  debilitated, 
sexual  and  other  excesses 
may  suffice. 

No  period  of  incubation. 
Symptoms  usually  appear 
in  a  few  hours. 


Inflammation  reaches  its 
height  in  a  few  hours. 
If  resulting  from  marked 
violence  to  the  urethra, 
symptoms  may  be  very 
severe;  otherwise  it  is 
usually  subacute  in  type. 

Acute  forms  usually  recover 
in  a  few  days,  as  do  the 
subacute  cases,  though 
the  latter  may  continue 
in  chronic  form. 

No  gonococci. 


The  microscopic  examination  should  be  conducted 
with  great  care,  all  instruments,  preparations,  slides,  and 
cover-glasses  being  scrupulously  clean.  If  the  first 
slide  examined  shows  typical  gonococci  in  abundance, 
and  all  the  other  evidence  points  to  a  gonorrhoea,  there 
is  practically  no  doubt  of  the  diagnosis ;  but  if  the  first 
slide  fails  to  show  gonococci,  at  least  six  or  eight  others 
should  be  properly  prepared  and  examined.  In  very 
early  stages,  while  the  discharge  is  composed  chiefly 
of  mucus  and  epithelial  cells,  the  gonococci  are  often 
present  in  very  small  numbers,  and  cannot  be  found  or 
differentiated  from  other  diplococci  for  three  or  four 
days,  during  which  time  many  slides  are  examined.  In 
the  declining  stage  it  is  even  more  difficult  to  find 
gonococci,  as  they  are  present  in  smaller  number  and 
are  not  infrequently  associated  with  other  micro-organ- 
isms which  lead  to  error  in  diagnosis.  Even  dur- 
ing the  purulent  stage    gonococci   are   not    evenly  dis- 


ACUTE    URETHRITIS.  367 

tributed  through  the  discharge,  but  are  usually  most 
abundant  in  those  drops  which  come  from  a  portion  of 
the  surface  most  recently  inflamed ;  consequently  it  is 
always  best,  for  purposes  of  examination,  to  squeeze 
out  a  drop  from  the  deeper  portions  of  the  urethra, 
instead  of  taking  that  which  happens  to  be  at  the 
meatus.  In  a  true  gonorrhoea,  however,  the  gonococci 
are  usually  present  in  sufficient  number  to  render  their 
demonstration  comparatively  easy,  and  the  discovery 
of  only  a  few  diplococci  in  an  acute  urethritis  does  not 
warrant  a  diagnosis  of  gonorrhoea.  The  dried  gonor- 
rhoeal  discharge  found  on  clothes  or  the  underwear  of 
a  patient,  if  moistened,  removed,  and  properly  stained, 
may  show  gonococci. 

Besides  the  gonococci  and  the  pus-cells  containing 
them,  the  microscope  shows,  in  the  earlier  discharge, 
many  columnar  or  fiat  epithelial  cells.  These  cells 
gradually  disappear,  and  the  field  is  completely  filled 
with  pus-cells,  which  in  turn  become  less  numerous  as 
the  discharge  decreases,  and,  if  the  case  progresses  to 
recovery,  gradually  disappear,  being  replaced  by  epithe- 
lial cells,  which  persist  in  the  discharge  during  the  period 
of  repair.  Both  pus  and  epithelial  cells  are  seen  in  the 
declining  stage  held  together  by  mucus  in  the  form  of 
threads  {tripper  f'dden),  described  in  detail  under  chronic 
urethritis. 

In  the  examination  of  any  urethral  discharge  the 
possible  presence  of  posterior  urethritis  should  always 
be  kept  in  mind.  If  the  urine  be  given  a  careful  exam- 
ination and  the  two-glass  method  be  employed,  this 
complication  of  gonorrhoea  will  not  be  neglected. 

Treatment. — Prophylaxis. — American  and  English 
writers  have  been  criticized  for  neglecting  to  discuss 
prophylaxis  in  their  works  on  gonorrhoea.  At  first 
thought  such  a  discussion  would  seem  superfluous,  but 
there  undoubtedly  exists  among  the  laity,  and,  unfor- 
tunately, among  some  physicians,  the  belief  that  there 
are  means  by  which  a  man  may  protect  himself  from 


368      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

venereal  diseases  while  indulging  in  promiscuous  sexual 
relations.  Of  the  various  devices  and  methods  recom- 
mended and  employed,  there  are  none  that  can  be 
trusted  to  ensure  the  desired  end.  The  large  majority 
of  men  who  resort  to  these  means  in  illicit  sexual  rela- 
tions sooner  or  later  become  infected  with  disease.  The 
only  prophylaxis  a  right-minded  physician  can  advise  is 
clean  living. 

General  Considerations. — In  the  entire  range  of  medi- 
cine there  are  few  diseases  in  which  so  many  remedies 
have  been  tried,  and  in  which  so  many  methods  of  treat- 
ment have  been  advocated,  as  in  gonorrhoea.  An  at- 
tempt to  describe  them  all  would  be  useless.  In  these 
pages  space  is  given  only  to  such  methods  of  treatment 
as  experience  has  proved  to  be  of  value  in  mitigating 
the  violence  or  in  shortening  the  duration  of  the  disease. 
These  methods,  unless  otherwise  indicated,  relate  to  the 
treatment  of  true  gonorrhoea.  The  discovery  of  gono- 
cocci  in  a  discharge  makes  it  possible  to  predict,  within 
certain  bounds,  the  intensity  and  duration  of  the  dis- 
order, demonstrates  its  contagious  nature,  and  calls  for 
much  care  and  caution  not  necessary  in  the  management 
of  a  non-infectious  urethritis.  In  the  latter,  the  dura- 
tion of  any  one  stage  is  brief  as  compared  with  the 
corresponding  stage  of  gonorrhoea,  and  treatment  other 
than  hygienic  is  rarely  called  for.  Usually  tremoval  of 
the  cause,  rest,  and  perhaps  an  alkali  to  ensure  a  bland 
condition  of  the  urine,  are  all  that  are  necessary.  In 
bastard  gonorrhoea  the  symptoms  are  usually  subacutej 
though  they  may  be  severe.  The  treatment  is  that  rec- 
ommended for  corresponding  stages  and  degrees  of 
inflammation  in  gonorrhoea. 

Abortive  Treatment. — Many  abortive  measures  for  the 
treatment  of  gonorrhoea  have  been  recommended  by 
reputable  physicians,  and  "  rapid  cures "  are  regularly 
advertised  in  the  public  press.  But  these  novel  methods 
that  promise  quick  results  are  not  unattended  by  danger. 
The  practitioner  who  is  strongly  tempted  to  try  the  last 


ACUTE    URETHRITIS.  369 

highly  recommended  local  treatment  in  the  hope  of 
benefiting  his  patient  should  recognise  these  dangers 
and  should  remember  that  there  is  a  great  difference 
between  checking    a  discharge  and  curing  the  disease. 

Since  the  recognition  by  Neisser  of  the  gonococcus  as 
the  essential  cause  of  gonorrhoea,  numerous  efforts  have 
been  made  to  discover  some  means  of  destroying  the 
micro-organism  and  of  thus  preventing  the  further  exten- 
sion and  continuation  of  the  disease.  Many  agents  are 
capable  of  at  once  destroying  the  gonococci  when  brought 
in  contact  with  them,  but  they  not  infrequently  either 
prove  so  destructive  to  tissue  or  so  aggravate  the  exist- 
ing inflammation  that  the  resulting  damage  to  the  urethra 
is  greater  than  that  produced  by  the  gonococcus.  Injec- 
tions of  strong  solutions  of  nitrate  of  silver  or  of 
bichloride  of  mercury  or  of  other  preparations  have  in 
some  instances  destroyed  the  micro-organism,  and  after 
causing  an  intense  inflammation  of  the  mucous  membrane 
have  seemed  to  shorten  the  duration  of  the  disease. 
More  frequently  such  treatment  has  failed  to  destroy  all 
the  gonococci,  and  has  resulted  in  complications  which 
prolong  the  disease  and  add  to  its  severity. 

A  local  application  that  will  meet  the  three  require- 
ments of  Neisser — that  is,  a  remedy  that  will  kill  the 
gonococcus,  leave  the  mucous  membrane  uninjured,  and 
not  increase  the  inflammation — is  yet  to  be  discovered. 
Up  to  the  present  time  attempts  at  abortive  treatment 
have  been  productive  of  much  harm  and  of  but  little 
good.  Many  cases  reported  to  have  been  aborted  by 
local  treatment  were  possibly  of  the  class  of  non-infec- 
tious urethritis  or  bastard  gonorrhoea,  that  would  in  any 
event  have  run  a  brief  course.  Others  were  perhaps 
cases  of  true  gonorrhoea,  dismissed  and  reported  as  cured 
as  soon  as  the  discharge  ceased.  It  is  now  known  that 
the  urethra  may  not  return  to  its  normal  condition  for 
weeks  after  the  discharge  disappears,  and  that  often  such 
cessation  of  the  discharge  proves  to  be  only  temporary. 

The  investigations  of  Bumm  and  others  have  shown 

24 


370      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

that  the  gonococci  rapidly  find  their  way  beneath  the 
epithelium  to  the  papillary  body  and  to  the  lymph-spaces 
of  the  upper  connective-tissue  layers.  Here  they  multi- 
ply and  are  brought  to  the  surface  by  the  leucocytes.  It 
is  thus  evident  that  after  the  gonococci  have  penetrated  be- 
neath the  surface  and  established  themselves  in  the  deeper 
tissues,  any  attempt  to  destroy  these  micro-organisms 
with  local  parasiticides  must  either  fail  or  do  permanent 
damage  to  the  urethra.  It  follows  that  this  method  of 
treatment  must  have  a  very  limited  field  of  usefulness, 
since  the  early  stage  of  gonorrhoea  is  not  seen  usually  by 
the  physician,  and  is  furthermore  distinguished  with  diffi- 
culty from  bastard  gonorrhoea  or  simple  urethritis,  as  the 
discharge  at  this  period  commonly  shows  but  few  gono- 
cocci. Attempts  at  abortive  treatment  are  thus  justified 
in  only  the  exceptional  cases  in  which  gonococci  can  be 
demonstrated  in  a  discharge  made  up  of  mucus  and  epi- 
thelium, with  very  few  or  no  pus-cells.  The  treatment 
frequently  fails  even  in  these  cases,  and  in  direct  propor- 
tion to  the  vigor  with  which  it  is  carried  out  is  painful 
and  liable  to  cause  such  complications  as  epididymitis 
and  prostatitis. 

The  most  effective  agent  for  the  destruction  of  gono- 
cocci is  nitrate  of  silver.  A  solution  containing  15 
grains  to  the  ounce  may  be  injected  into  the  first  two 
inches  of  the  urethra  and  allowed  to  remain  a  few 
seconds,  after  which  the  urethra  is  immediately  washed 
out  with  a  normal  salt  or  weak  alkaline  solution  and  the 
patient  urinates.  Or  the  patient  may  first  urinate  and 
the  urethra  be  further  cleansed  by  irrigating  with  a  warm 
solution  of  boric  acid;  after  which  a  short  endoscopic 
tube  is  introduced  to  a  depth  of  three  inches,  the  obtu- 
rator is  withdrawn,  a  wad  of  cotton  soaked  in  the  solu- 
tion of  nitrate  of  silver  is  carried  on  an  applicator  just 
beyond  the  inner  end  of  the  tube,  and  the  whole  slowly 
withdrawn.  The  application  of  the  nitrate  of  silver  by 
either  method  is  followed  by  a  more  or  less  violent  reac- 
tion and  inflammation,  with  destruction  of  the  outer  epi- 


ACUTE    URETHRITIS.  37 1 

thelial  layers,  the  discharge  becoming  purulent,  or  even 
hemorrhagic,  in  a  few  hours.  The  patient  should  there- 
fore rest  in  bed  and  be  given  a  light  diet,  laxatives,  if 
necessary,  and  diluents  or  alkalies  to  render  the  urine 
unirritating.  Very  hot  or  very  cold  applications  to  the 
penis  sometimes  serve  to  allay  the  pain.  In  favorable 
cases  the  discharge  gradually  ceases  in  the  course  of  a 
week  or  ten  days  ;  in  unsuccessful  cases  the  acute  symp- 
toms of  the  disease  are  usually  made  more  severe  by  the 
treatment. 

A  less  dangerous  and  equally  satisfactory  method  is 
found  in  the  use  of  protargol Y  in  solutions  of  from  \ 
to  1  per  cent.  These  solutions  are  injected  into  the 
anterior  urethra  three  or  four  times  a  day,  each  injection 
being  allowed  to  remain  for  from  five  to  twenty  minutes. 
The  solutions  should  not  be  strong  enough,  or  left  in  the 
urethra  long  enough,  to  produce  pain  or  marked  irrita- 
tion. The  gonococci  are  said  to  disappear  in  from  eight 
to  twenty  days,  after  which  milder  solutions  are  used, 
followed  by  simple  astringent  injections. 

Prolonged  irrigation  twice  daily  with  hot  solutions  of 
potassium  permanganate  (1  :  5000  to  I  :  1000),  bichlo- 
ride of  mercury  (1  :  8000  to  1  :  3000),  or  nitrate  of 
silver  (1  :  6000  to  I  :  3000),  are  highly  recommended 
by  some  writers.     Their  efficacy  is  very  doubtful. 

Hygienic  Management. — There  is  practical  unanimity 
of  opinion  on  at  least  one  point  in  the  treatment  of 
gonorrhcea — namely,  that  proper  hygienic  surroundings 
are  of  great  importance.  There  is  no  better  treatment 
for  the  large  majority  of  all  first  attacks  of  gonorrhcea 
than  rest  in  bed  for  from  one  to  three  or  four  weeks, 
with  absolute  quiet,  freedom  from  sexual  excitement,  a 
light  and  simple  diet,  a  daily  movement  of  the  bowels 
and  a  proper  performance  of  the  other  bodily  functions. 
Unfortunately,  it  is  rare  that  such  a  course  can  be  pur- 
sued.    Few  men  with  a  gonorrhoea  are  willing,  unless 

1  Argonin,  largin,  and  other  compounds  of  silver  with  albumin  may  be 
used  instead  of  protargol. 


372      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

compelled  to  do  so,  to  abandon  their  usual  vocation,  and 
many,  through  fear  of  disclosing  their  condition,  will 
continue  their  work,  contrary  to  their  physician's  orders, 
notwithstanding  most  painful  complications.  Through 
fear  of  betraying  his  secret  to  his  companions  or  to  mem- 
bers of  his  household  a  man  will  often  fail  to  obey  the 
instructions  given  him,  and  refuse  to  change  his  habits 
to  meet  the  requirements  of  his  case.  An  average  case 
of  gonorrhoea  is  a  much  more  serious  matter,  and  is 
fraught  with  far  more  danger  to  health  and  life,  than  is 
an  ordinary  fracture  of  one  of  the  bones.  Yet  in  the 
latter  case  the  patient  readily  assents  to  rest,  while  in  the 
former  it  is  rare  that  this  important  element  in  treatment 
can  be  obtained. 

One  of  the  first  points,  therefore,  to  be  secured  in  the 
management  of  a  case  of  gonorrhoea  is  a  complete  under- 
standing on  the  part  of  a  patient  that  it  is  necessary  for 
him  to  carry  out  faithfully  the  instructions  given,  and 
that  he  is  thus  responsible,  to  a  great  extent,  for  the 
result.  This  is  not  usually  an  easy  matter,  as  the  idea 
is  often  firmly  fixed  in  the  mind  of  the  patient  that  an 
injection  will  accomplish  all  that  is  necessary,  with  little 
or  no  effort  on  his  part.  The  practitioner  who  takes  the 
time  and  pains  to  point  out  the  truth  will  have  far  better 
results,  and  meet  with  much  less  annoyance,  than  if  he 
devote  his  time  to  making  trial  of  the  last  highly  recom- 
mended and  best-advertised  injections.  The  manage- 
ment of  gonorrhoea  cannot  be  made  a  matter  of  routine, 
but  requires  always  some  consideration  of  the  individual 
and  his  surroundings.  Directions  should  be  given 
clearly  and  in  detail. 

(a)  Rest. — The  patient  should  be  made  to  understand 
the  force  of  the  statement  made  in  the  preceding  para- 
graph, and  should  spend  all  the  time  possible  in  the 
recumbent  position.  This  is  of  special  service  during  the 
early  acute  stages,  since,  by  removing  the  pressure  of 
blood  from  above,  congestion  of  the  parts  is  lessened.  All 
violent  exercise,  such  as   gymnastics,  running,  dancing, 


ACUTE    URETHRITIS.  373 

and  horseback-  or  bicycle-riding,  should  not  be  practised, 
and  even  walking  or  much  standing  is  harmful. 

(b)  Food. — The  more  nearly  the  patient  can  restrict 
himself  to  bread  and  water  or  bread  and  milk  the 
better ;  but  if  he  must  continue  his  usual  work  or  a 
portion  of  it,  or  if  he  be  already  poorly  nourished,  a 
more  nutritious  diet  may  be  necessary.  Such  he  may  find 
in  fish,  the  lighter  meats,  soft-boiled  eggs,  and  cooked 
vegetables.  As  a  rule,  he  should  avoid  all  articles 
difficult  of  digestion,  all  rich  or  highly  seasoned  food, 
and  all  acids,  sweets,  and  especially  fats. 

(c)  Beverages. — Alcohol  in  all  forms,  and  especially 
in  the  form  of  malt  liquors,  is  prohibited.  Coffee, 
chocolate,  and  cocoa  are  injurious,  but  tea  in  modera- 
tion may  be  allowed.  Milk  is  of  value,  and  may  be 
given  freely  if  it  agrees  with  the  individual.  Pure  water 
does  excellent  service  if  drunk  in  quantities  sufficient  to 
keep  the  urine  bland  and  unirritating.  Smaller  amounts 
of  Vichy,  Seltzer,  or  other  alkaline  waters  answer  much 
the  same  purpose,  except  that  the  ingestion  of  large 
quantities  of  fluid  serves  the  additional  purpose  of  fre- 
quently irrigating  and  cleansing  the  urethra.  If  there  be 
much  burning  on  urinating,  and  frequent  desire  to  pass 
urine,  a  thin,  strained,  fiaxseed-tea  (made  from  the  whole 
seed  and  rendered  palatable  by  the  addition  of  a  small 
quantity  of  lemon-peel)  will  often  give  relief  if  drunk  in 
quantities  of  a  quart  or  more  daily.  Instead  of  flaxseed, 
slippery-elm,  sea-moss,  arrow-root,  sassafras-pith,  bar- 
ley, or  gum-arabic  may  be  used.  Lemonade  is  usually 
agreeable  to  the  patient,  and,  like  some  other  vegetable 
acids,  is  occasionally  of  service  in  rendering  the  urine 
alkaline,  the  more  so  if  a  small  quantity  of  bicarbonate 
of  soda  be  added  ;  but  it  does  not  answer  equally  well  in 
all  cases,  and  sometimes  proves  decidedly  irritating. 

(d)  Tobacco  in  all  forms  should  be  avoided.  Smok- 
ing is  especially  bad. 

(e)  All  sexual  relations  and  stimulation  of  the  sexual 
organs  are  harmful,  and  the  patient  should  avoid  com- 


374      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

pany,  books,  pictures,  thoughts,  and  circumstances  that 
might  result  in  sexual  excitement.  His  determined  and 
persistent  assistance  in  this  direction  is  the  more  impor- 
tant since  the  congestion  and  inflammation  of  the  parts, 
due  to  his  gonorrhoea,  are  alone  sufficient  to  keep  them 
in  a  state  of  irritation.  For  the  purpose  of  lessening  the 
tendency  to  congestion  of  the  genitals,  there  should  be  a 
daily  evacuation  of  the  bowels  by  the  aid  of  saline  laxa- 
tives. The  patient  should  sleep  on  his  side,  in  a  cool 
room,  on  a  hard  mattress,  and  without  too  much  cover- 
ing :  the  married  man  should  not  occupy  the  same  bed 
with  his  wife.  The  immersion  of  the  genitals  in  water  as 
hot  as  can  be  tolerated,  and  for  a  few  minutes  only,  just 
before  retiring,  often  reduces  the  frequency  of  annoying 
and  painful  erections.  A  longer  use  of  cold  water  may 
answer  the  same  purpose,  and  both  means  are  valuable 
in  reducing  erections  which  awaken  the  patient  during 
the  night.  Prolonged  warm  baths  are  often  harmful  in 
that  they  encourage  local  congestion  ;  but  a  hot  bath 
or  sitz-bath,  taken  just  before  retiring,  and  immersion  of 
the  penis  three  or  four  times  daily,  for  fifteen  minutes  at 
a  time,  in  water  as  hot  as  can  be  tolerated  with  com- 
fort, are  measures  that  frequently  lessen  the  local  con- 
gestion and  give  relief.  Urinating  while  the  penis  is  im- 
mersed in  hot  water  usually  renders  that  act  less  painful. 
(/)  Dressing  of  the  Parts. — Cleanliness  is  of  first  im- 
portance ;  the  parts  should  be  washed  daily  in  warm 
water,  using  soap  on  all  but  the  inflamed  surfaces,  and, 
of  course,  keeping  it  out  of  the  urethra.  The  patient 
should  wash  his  hands  after  each  dressing,  and  should 
be  instructed  regarding  the  great  danger  attending  the 
contact  of  the  smallest  amount  of  the  discharge  with  the 
eyes.  To  catch  the  discharge  and  to  protect  the  patient's 
clothing,  the  penis  may  be  carried  in  a  light  muslin  bag 
(or  the  toe  of  a  stocking),  containing  in  the  bottom  a 
small  quantity  of  cotton,  the  bag  being  fastened  by 
means  of  a  tape  to  a  suspensory  bandage  or  to  a 
band    about   the    waist.     The  bag  must    be   of  loosely 


ACUTE    URETHRITIS.  375 

woven  material,  and  long  enough  to  prevent  the  meatus 
being  covered  by  the  cotton.  A  simple  and  very  satis- 
factory method  is  to  take  two  thicknesses  of  ordinary 
muslin,  about  a  foot  square,  and  so  pin  them  to  the  inner 
surface  of  the  undershirt  that  the  penis  can  be  gathered 
up  in  their  folds.  These  cloths  are  cheap,  and  can  easily 
and  quickly  be  removed,  burned,  and  replaced  by  fresh 
pieces  several  times  during  the  day.  If  desired,  a  pair 
of  swimming-drawers  can  be  worn  beneath  the  other 
underwear,  and  will  serve  to  hold  the  muslin  in  better 
position.  Keyes  recommends  wrapping  the  penis  in 
two  sheets  of  ordinary  toilet  paper  and  twisting  the 
free  end,  forming  a  paper  bag  in  which  to  catch  the 
discharge. 

Rubber  and  oiled-silk  bags,  and  all  heavy  wrappings 
of  the  penis,  are  decidedly  harmful,  in  that  they  tend 
to  keep  the  organ  hot  and  congested.  Dressings 
should  never  be  tied  to  or  about  the  penis,  since  they 
interfere  with  the  circulation  and  usually  cause  a  trou- 
blesome cedema  of  the  prepuce.  Nor,  for  catching  the 
discharge,  are  pieces  of  cotton  or  other  dressings  held 
in  place  by  a  long  prepuce  to  be  recommended,  since 
they  imprison  the  pus  within  the  urethra,  and  also  keep 
it  in  contact  with  the  sensitive  mucous  membrane  of  the 
glans  and  prepuce,  thus  often  exciting  a  balanitis. 

If  the  patient  is  required  to  be  active  or  on  his  feet 
much  of  the  time,  and  particularly  if  with  a  former 
gonorrhoea  he  has  had  an  epididymitis,  he  should  wear 
a  well-fitting  suspensory  bandage.  The  first  object  of  a. 
suspensory  is  to  support  and  elevate  the  scrotum  and 
the  testicles,  relieving  the  tension  on  the  cord,  at  the 
same  time  slightly  lessening  the  blood-pressure  and  aid- 
ing the  return  circulation.  This  object  can  be  accom- 
plished by  a  single  bag  of  proper  depth  and  width  to  fit 
the  parts,  suspended  only  from  a  waistband.  The  bag 
must  not  be  too  deep,  or  it  will  not  furnish  support ; 
while  if  too  shallow  it  will  exert  uneven  pressure  and 
will  slip  off,  not  retaining  the  parts.     Frequently  a  bag 


376      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

that  does  not  fit  well  can  be  made  to  do  so  by  lining  and 
filling  out  some  parts  of  it  with  antiseptic  wool.  Cotton 
is  not  so  good,  as  it  soon  mats  and  becomes  hard. 

This  simple  suspension  of  the  genitals  may  be  sufficient 
in  many  cases,  but  if  there  be  the  slighest  tendency  to  in- 
volvement of  the  cord  or  the  testicles,  another  object  is 
to  be  accomplished — the  subjection  of  the  testicles  to 
as  little  motion  as  possible  in  walking  or  during  other 
movements.  For  this  purpose  the  suspensory  bandage 
described  above  will  need,  in  addition,  some  perineal  or 
thigh-straps  that  will  hold  the  organs  snugly  against  the 
symphysis.  In  order  to  do  good,  and  not  harm,  a  sus- 
pensory must  fit  snugly,  but  must  not  be  too  tight,  nor 
should  it  press  upon  any  portion  of  the  urethra.  It  is 
usually  most  serviceable  when  it  is  most  comfortable  to 
the  patient.  Instead  of  a  suspensory  bandage  a  jock- 
strap may  be  used,  though  it  is  not  so  convenient  and  is 
usually  more  difficult  to  fit  properly.  Tight -fitting 
swimming-drawers  of  firm  material  often  answer  every 
purpose.  An  excellent  substitute  for  any  of  the  pre- 
ceding may  easily  be  made  as  follows :  Pass  a  bandage, 
of  such  material  and  width  as  will  be  comfortable,  around 
the  waist  for  a  belt ;  take  a  strip  of  soft  linen  or  several 
thicknesses  of  cheese-cloth  or  mull,  about  eight  inches 
wide,  and  fasten  one  end  of  this  to  the  middle  of  the  belt 
behind  with  safety-pins  ;  bring  it  between  the  buttocks, 
over  the  perineum,  and  up  to  the  belt  in  front,  where,  by 
fastening  at  several  points,  it  can  be  made  to  fit  the  genitals, 
elevating  them  and  holding  them  close  against  the  body. 

Internal  Treatment. — In  the  early  stages  hygienic 
management  is  of  first  importance.  Fournier  and  other 
French  authorities  advocate  no  other  treatment  internally 
or  locally  until  the  stage  of  decline.  This  is  the  so- 
called  "  expectant  plan."  While  the  use  of  large  doses 
of  the  balsams  with  a  view  to  aborting  the  disease  is 
not  to  be  recommended,  its'  early  stages  may  be  rendered 
much  less  severe,  and  the  entire  course  of  gonorrhoea 
be  shortened,  by  the  proper  use  of  internal  remedies. 


ACUTE    URETHRITIS.  377 

Alkalies  and  diuretics  are  of  decided  value  in  keeping 
the  urine  bland  and  unirritating,  and  should  be  used  in 
sufficient  doses  throughout  the  disease  to  accomplish 
that  end,  unless  the  fluids  daily  ingested  prove  sufficient 
for  the  purpose.  Excellent  results  are  obtained  from 
the  use  of  bicarbonate  of  sodium  or  potassium  or  of 
citrate  or  acetate  of  potassium  in  doses  of  from  5  to  20 
grains  three  or  four  times  daily;  the  two  latter  act  also  as 
diuretics,  and  are  in  some  cases  to  be  preferred.  The  quan- 
tity required  will  vary  from  day  to  day,  enough  being 
given  to  keep  the  urine  alkaline.  If  taken  about  two 
hours  after  eating,  the  effect  upon  the  urine  is  more  pro- 
nounced than  if  given  at  any  other  time,  and  interference 
with  digestion  is  not  so  marked  as  when  taken  imme- 
diately after  eating.  Consequently  it  is  often  well  to 
prescribe  these  remedies  in  the  form  of  compressed 
tablets  of  5  grains  each,  that  can  be  carried  in  the  pocket 
and  swallowed  at  any  time  after  having  been  dissolved 
in  a  glass  of  water.  They  may  also  be  given  in  simple 
solution,  in  peppermint-water,  or  with  any  flavoring  de- 
sired. In  acute  cases  with  much  pain  and  frequency  of 
urination,  hyoscyamus  in  some  form,  administered  in 
small  doses  four  or  five  times  a  day,  will  often  give  relief. 

Balsam  of  copaiba,  if  easily  digested  by  the  patient, 
is  one  of  the  most  valuable  of  drugs,  but  there  are 
unquestionably  certain  individuals  who  cannot  digest  it. 
It  should  never  be  ordered  if  it  disturbs  digestion  and 
nauseates  so  that  the  patient  cannot  eat,  though  many 
who  at  first  had  some  difficulty  in  its  digestion  soon 
manage  very  well  if  it  be  taken  in  small  but  gradually 
increasing  doses  an  hour  or  two  after  eating  (occasion- 
ally some  other  hour  will  be  found  to  be  better),  or  if 
some  preparation  of  pepsin  be  taken  with  it.  Occasion- 
ally a  few  doses  of  the  drug  cause  the  appearance  of  an 
exanthem  known  as  the  copaiba  rash.  This  is  a  bright 
red  eruption  of  macules  or  maculo-papules  over  the 
abdomen  and  the  extremities,  or  even  over  the  entire 
skin-surface.     The  eruption  appears  rapidly  and   is  ac- 


3/8      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

companied  by  pruritus.  It  is  a  trifling  complication,  dis- 
appearing promptly  on  withdrawal  of  the  copaiba,  but  it 
is  a  source  of  annoyance  to  the  patient  and  necessitates 
the  abandonment  of  the  drug. 

If  copaiba  is  digested  reasonably  well,  it  is  usually 
of  great  service  and  may  be  given  from  the  beginning, 
though  if  digested  with  some  difficulty  its  use  should 
be  postponed  until  the  stationary  or  declining  stage,  at 
which  time  it  is  of  pronounced  value.  Many  object  to 
the  use  of  the  balsamic  preparations  in  the  early  stages 
of  gonorrhoea,  on  the  ground  that  they  are  stimu- 
lating to  the  mucous  membrane.  Clinical  experience, 
however,  teaches  that  in  the  majority  of  cases  copaiba 
very  markedly  lessens  not  only  the  discharge,  but 
also  the  painful  and  distressing  symptoms  of  the 
acute  stages,  and,  moreover,  shortens  the  duration 
of  the  disease.  Finger  states  that  he  believes  copaiba 
taken  internally  acts  in  the  urine  as  a  parasiticide, 
destroying  some  of  the  gonococci.  The  action  of 
copaiba  (and  allied  drugs,  such  as  sandalwood  and 
cubebs)  is  undoubtedly  local,  and  is  due  either  to  the 
drug  itself  or  to  the  products  of  its  metamorphosis 
present  in  the  urine  as  it  passes  over  the  mucous  mem- 
brane of  the  urethra.  This  fact  was  demonstrated  by 
Ricord  and  Roquette  in  patients  with  urethral  fistulae 
who  acquired  gonorrhoea.  While  taking  copaiba  inter- 
nally the  portion  of  the  urethra,  back  of  the  fistula,  that 
was  washed  by  the  urine  showed  marked  improvement, 
while  no  change  was  apparent  in  the  part  anterior  to  the 
fistula,  and  through  which  no  urine  passed.  The  patient 
continuing  the  internal  use  of  the  balsam,  some  of  his 
urine  was  injected  into  this  anterior  portion  of  his 
urethra,  the  result  being  a  lessening  of  the  inflammation. 

In  examining  the  urine  of  a  patient  who  is  taking 
copaiba  it  must  be  remembered  that  the  mineral  acids 
produce  with  it  a  flocculent  precipitate  which  can  easily 
be  mistaken  for  albumin.  This  precipitate  is  soluble  in 
an  excess  of  acid  or  in  alcohol.     Copaiba  is  best  given 


ACUTE    URETHRITIS.  379 

in  the  form  of  the  balsam,  either  in  capsules  of  10  minims 
each  or  in  one  of  the  following  preparations  : 
Tfy.  Balsam,  copaibse,  Sss-ij ; 

Syr.  tolutani,  ^j— ij ; 

Acaciae  pulvis, 

Sacchar.  albi,  da.  q.  s.  ad  ft.  emuls. 
Lavand.  spirit.,  oj ; 

Aquae  destill.,  q.s.  ad  Svj. — M. 

Ft.  emulsio. 
Sig.  Teaspoonful  dose. 

i^.   Potassae  citratis,  3ij— vj ; 

Balsam,  copaibae,  3iij-vj ; 

Extr.  fl.  hyoscyami,  3ss-3ij ; 

Syr.  acaciae,  5iss ; 

Aquae  menth.  pip.,    q.  s.  ad  3iij. — M. 
Sig.  Shake.  Teaspoonful  in  water. 

The  last  preparation  is  recommended  by  Keyes,  who 
adds  that  "  The  mixture  may  be  largely  modified  by  sub- 
stituting sandalwood  oil  for  copaiba,  leaving  out  the 
hyoscyamus  when  not  required,  substituting  bicarbonate 
of  soda  for  the  citrate  of  potash  if  the  diuretic  effect  is 
not  desired,  and  wintergreen-water  for  mint-water,  or 
even  adding  licorice,  according  to  taste."  Oil  of  sandal- 
wood or  oil  of  cubebs  may  be  added  to  either  of  the 
above  emulsions  if  desired. 

The  remarks  made  with  reference  to  copaiba  apply  in 
the  main  to  the  oil  of  sandalwood.  The  latter  is,  how- 
ever, more  easily  digested  and  does  not  produce  an 
exanthem,  though  it  may  cause  congestion  of  the  kidneys 
with  resulting  characteristic  pains  in  the  back  and  the 
loins.  In  a  majority  of  cases  less  uniform  results  are 
obtained  from  the  oil  of  sandalwood  than  from  copaiba  ; 
but  while  it  is  not  so  efficacious  in  subduing  the  painful 
symptoms  of  the  acute  stages,  it  often  seems  more  effec- 
tive in  reducing  a  subacute  discharge.  It  should  be 
tried  in  the  acute  stages  instead  of  copaiba  when  the 
latter  is  not  tolerated.     It  is  best  given  in  capsules  each 


3iO      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

of  10  minims;  or  it  may  be  dropped  on  lump-sugar,  in 
which  case  an  ounce  of  sandalwood  oil  may  be  flavored 
by  adding  to  it  10  or  15  drops  of  the  oil  of  wintergreen 
or  the  oil  of  peppermint ;  or  it  may  be  substituted  for 
copaiba  in  either  of  the  emulsions  for  which  formulas 
have  been  given. 

Preparations  of  citbebs  are,  as  a  rule,  too  stimulating  to 
be  given  while  the  inflammatory  symptoms  are  at  all 
marked.  They  are  of  great  service  in  checking  the  last 
drops  of  a  lingering  discharge,  either  at  the  close  of  an 
acute  case  or  in  subacute  and  chronic  cases.  They 
usually  cause  no  disturbance  in  digestion,  and. they  fre- 
quently act  as  tonics  to  the  stomach.  The  best  prepa- 
ration, if  fresh,  is  the  powder.  It  should  be  given  in 
doses  of  from  10  grains  to  2  drachms.  When  desired 
by  the  patient,  it  may  be  given  in  capsules  or  be  admin- 
istered in  some  syrupy  or  mucilaginous  drink.  The 
oleoresin  in  10-minim  capsules,  from  one  to  three  at  a 
dose,  is  perhaps  as  good  as  the  powder;  while  the  fluid 
extract  in  from  10-minim  to  drachm  doses  often  gives 
good  results.  In  stubborn  cases  of  subacute  and  torpid 
type  it  is  advisable  to  make  occasional  changes  in  the 
preparations  given.  Good  results  are  often  obtained 
from  a  combination  of  cubebs  and  sandalwood,  with  the 
addition  sometimes  of  copaiba. 

In  prescribing  any  one  or  all  of  these  preparations  sev- 
eral rules  should  be  observed.  A  dose  on  retiring  for 
the  night  should  be  given,  in  addition  to  that  after  each 
meal,  thus  keeping  the  urine  constantly  under  the  influ- 
ence of  the  drug.  The  doses  should  be  small  at  first, 
particularly  in  the  early  stages,  and  should  gradually  be 
increased  up  to  the  full  tolerance  of  the  patient's  stomach, 
or  until  the  desired  effect  is  produced  ;  for  if  this  can  be 
accomplished  in  smaller,  it  will,  of  course,  be  worse  than 
useless  to  give  larger  doses.  If,  after  a  week  or  two  of 
full  doses,  no  benefit  has  been  derived  from  the  drug 
(provided  always  that  the  patient  has  had  proper  hygienic 
management  and  surroundings),  or  if  the  patient's  stomach 


ACUTE    URETHRITIS.  38 1 

begin  to  rebel,  a  change  to  one  of  the  other  preparations 
should  be  made.  No  one  of  these  remedies,  particularly 
copaiba,  should  be  given  continually  through  too  long 
a  period.  If,  at  the  end  of  one,  two,  three,  or  four  weeks, 
symptoms  of  gastric  disturbance  begin  to  appear,  or  if, 
in  the  case  of  sandalwood,  there  are  indications  of  con- 
gestion of  the  kidneys,  such  as  pain,  or  a  sense  of  burn- 
ing and  oppression  in  the  loins,  another  drug  should  at 
once  be  substituted.  It  should  be  remembered  that  the 
market  is  flooded  with  cheap  and  poor  preparations  of 
these  drugs,  and  only  those  of  reliable  manufacture 
should  be  used. 

Urotropin,  boric  acid,  methylene  blue,  or  salol  may  be 
given  in  conjunction  with  the  balsams.  They  are  of 
value  in  rendering  the  urine  antiseptic.  In  a  case  of 
secondary  infection  of  the  bladder  urotropin  or  boric 
acid  should  be  given  to  clear  the  urine. 

Treatment  of  Successive  Stages  of  Gonorrlicea. — Atten- 
tion to  all  the  details  of  hygienic  management  are  of 
the  greatest  importance  in  all  the  stages  of  gonorrhoea, 
and  have  been  fully  discussed  in  the  preceding  pages. 

{A)  Prodromal  Stage. — It  is  not  often  that  the  physi- 
cian has  a  chance  to  observe  this  stage  of  the  disease, 
which  usually  lasts  but  a  day  or  two,  and  passes  un- 
noticed by  the  average  man  unless  he  is  watching  him- 
self in  fear  of  the  possible  result  of  a  suspicious  inter- 
course. If  there  is  a  clear  history  of  exposure  followed 
by  a  period  of  incubation,  and  certainly  if  there  can  be 
expressed  a  drop  of  mucus  in  which  there  are  a  few 
gonococci,  gonorrhoea  will  undoubtedly  follow,  and  the 
patient  should  be  put  under  hygienic  treatment  at  once, 
with  the  addition  of  an  alkali  internally.  Abortive 
measures  (page  368)  are  to  be  tried  only  in  exceptional 
cases,  and  then  at  the  request  of  the  patient,  after  he  has 
been  fully  instructed  regarding  the  possible  results.  If 
circumstances  point  rather  to  the  presence  of  a  non- 
infectious urethritis,  hygienic  treatment  and  an  alkali  will 
do  no  harm,  though  it  may  not  be  necessary  to  interfere 


382      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

to  the  same  extent  with  the  patient's  habits  of  living, 
removal  of  the  cause  if  discovered,  the  administration  of 
an  alkali,  and  rest  being  in  the  majority  of  cases  all  the 
treatment  that  is  necessary.  The  general  condition  of 
the  patient  may  call  for  consideration. 

{E)  Increasing  Stage. — During  this  stage  the  patient 
with  a  well-managed  case  of  gonorrhoea  usually  finds 
his  chief  source  of  anxiety  in  the  urethral  discharge,  and 
looks  upon  its  daily  increasing  amount  with  much  ap- 
prehension. It  is  then  that  the  physician  is  tempted  to 
satisfy  his  patient  by  using  methods  that  will  promptly 
check  the  discharge,  and  in  this  course  there  may  be 
danger.  Often,  by  too  vigorous  local  treatment  the 
modification  of  the  discharge  is  followed  by  complica- 
tions so  painful  and  distressing  that  the  sufferer  would 
gladly  welcome  a  return  to  the  discharge  if  he  could  be 
relieved  from  his  new  and  serious  symptoms.  The 
treatment  in  this  stage  should  therefore  be  directed  more 
to  the  alleviation  and,  if  possible,  prevention  of  painful 
symptoms  and  complications,  and  to  the  general  condition 
of  the  individual,  than  to  the  suppression  of  the  discharge. 

The  pain  and  burning  on  urinating — ardor  nrince — 
should  be  controlled,  if  possible,  by  drinking  large  quan- 
tities of  fluid  to  dilute  the  urine,  and,  as  already  described, 
by  the  use  of  alkalies.  This  object  will  nearly  or 
wholly  be  accomplished  when  the  urine  is  kept  alkaline. 
Some  preparation  of  copaiba  or  of  sandalwood  may  then 
be  given  in  small  doses.  In  cases  where  the  pain  is 
very  great,  much  relief  is  afforded  by  immersing  the 
penis  in  hot  water  during  the  act  of  urinating.  If  these 
means  are  found  in  any  case  to  be  impracticable,  the 
fluid  extract  of  hyoscyamus  may  be  given  with  the  alkali 
several  times  a  day,  in  doses  of  from  1  to  5  minims.  The 
injection  of  a  weak  solution  of  cocaine  just  before  urinat- 
ing is  recommended  by  some  authors,  but  its  use  does 
not  to  any  great  extent  lessen  the  amount  of  pain,  and 
it  must  be  remembered  that  deaths  have  been  reported 
from  the  use   of  cocaine  in  the   urethra. 


ACUTE    URETHRITIS.  383 

In  cases  of  complete  retention  or  where  the  urine  will 
pass  in  drops  only,  a  good  plan  is  to  place  the  patient  in 
a  hot-water  bath — a  sitz-bath  will  answer — and  allow 
him  to  stay  there  quietly  for  a  few  minutes,  an  hour  if 
necessary,  until  the  urine  passes.  This  is  a  most  effec- 
tual means  of  emptying  the  bladder  without  distress  to 
the  patient,  and  it  usually  enables  him  to  urinate  with 
much  less  difficulty  the  next  time  the  act  is  attempted. 
Rarely  this  procedure  will  not  suffice,  and  a  catheter 
must  be  used;  this  should  be  soft  and  small,  in  size 
about  No.  12  or  14  of  the  French  scale,  and  should  be 
introduced  with  great  care,  after  first  irrigating  the  urethra 
with  a  mild  warm  solution  of  boric  acid  or  borax,  and 
injecting  warm  oil  which  is  retained  until  the  catheter 
is  passed,  so  that  the  inflamed  membrane  may  be 
damaged  as  little  as  possible.  The  operation  is  made 
still  easier  if,  in  addition  to  the  above  precautions,  the 
catheter  is  passed  while  the  patient  reclines  in  the  bath. 
A  careless  use  of  the  catheter  will  damage  the  mucous 
membrane,  add  to  its  swollen  condition,  and  therefore 
increase  the  urethral  obstruction.  If  other  means  fail, 
ice  in  the  rectum  may  be  tried.  It  should  be  pulverized 
and  put  in  a  suitably  shaped  flannel  bag.  Finally,  aspi- 
ration may  be  necessary.  Complete  retention  is,  how- 
ever, unusual,  unless  the  patient  before  acquiring  his 
gonorrhoea  had  a  stricture. 

The  treatment  of  chordee  and  other  forms  of  sexual 
irritation  attending  gonorrhoea  must  be  chiefly  hygienic, 
and  has  already  been  considered,  the  requirements,  in 
brief,  being  avoidance  of  all  sexual  excitement,  a  light  diet, 
regular  daily  evacuation  of  the  bowels,  sleeping  in  a  cool 
room  on  a  hard  mattress  without  too  much  covering, 
and  a  hot  sitz-bath,  or  the  immersion  of  the  penis 
for  a  few  minutes  in  hot  water  or  for  a  longer  period 
in  cold  water,  just  before  retiring,  to  be  repeated 
during  the  night  if  necessary  to  reduce  painful  erec- 
tions. If  the  patient  is  in  the  habit  of  sleeping  on  his 
back,   he    may  lessen    the   congestion   of  the    genitals 


384      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

by  lying  on  his  side.  He  can  force  himself  to  do  this 
by  tying  a  towel  about  his  waist  with  the  knot  resting 
on  his  spine.  If  all  these  details  are  faithfully  carried 
out,  it  is  rare  that  camphor,  belladonna,  lupulin,  bromide 
of  potassium,  and  other  so-called  "  anaphrodisiacs  "  will 
be  needed,  or,  if  tried,  will  be  found  beneficial.  They 
are  all  unsatisfactory,  and  frequently  disturb  the  func- 
tions of  other  organs  of  the  body.  Lupulin  is  probably 
the  best  of  the  list,  and  bromide  of  potassium  the  next, 
but  to  produce  more  than  a  moral  effect  they  must  be 
given  in  large  doses.  In  extreme  cases  opium  and  bel- 
ladonna suppositories  may  be  used  in  the  rectum  until 
relief  is  obtained  through  other  measures.  Excessive 
restlessness  and  nervousness,  slight  febrile  reaction,  vague 
and  shifting  pains,  and  other  phenomena  indicating  a 
mild  toxaemia,  should  be  combated  by  securing  proper 
elimination,  and  by  the  use  of  quinine,  salicylate  of  sodium, 
antipyrin,  phenacetin,  etc. 

The  treatment  of  the  complications  that  may  occur 
during  these  and  the  succeeding  stages  of  gonorrhoea  is 
separately  considered. 

(a)  Local  Treatment. — The  treatment  of  gonorrhoea 
will  at  some  future  date,  perhaps,  be  purely  local,  but 
there'  has  not  yet  been  found  a  method  of  local  treat- 
ment in  the  acute  stages  of  gonorrhoea  that  is  completely 
efficacious,  or  even  safe  in  the  hands  of  any  but  the 
expert. 

The  so-called  "  Janet  method  "  of  irrigating  the  entire 
urethra,  by  means  of  hydrostatic  pressure,  with  large 
quantities  of  warm  solution  of  potassium  permanganate 
is  highly  recommended  by  some  writers,  and  has  become 
very  popular.  It  is  based  upon  the  fact  that  the  resist- 
ance of  the  cut-off  muscle  of  the  urethra  may  be  over- 
come by  hydrostatic  pressure,  and  thus  the  deep  urethra 
and  bladder  be  irrigated  without  the  use  of  a  catheter. 
Instead  of  relying  entirely  upon  pressure  it  is  far  better 
to  instruct  the  patient  to  relax  the  muscle  voluntarily  by 
drawing  a  deep  breath  and  making  a  mild  but  continued 


ACUTE    URETHRITIS. 


385 


effort  to  urinate.  Most  patients  can  learn  to  do  this. 
Those  who  cannot  are  not  fit  subjects  for  this  method  of 
treatment. 

Irrigation  may  be  accomplished  with  a  fountain  syringe 
connected  by  rubber  tubing  with   a  short,  blunt   glass 


r 


ID 


Fig.  15. — Irrigation  nozzles. 


nozzle  that  will  completely  close  the  meatus  without 
projecting  further  into  the  urethra  (Fig.  15).  A  more 
convenient  and  cleanly  apparatus  is 
shown  in  the  accompanying  cut  (Fig. 
16).  The  patient's  clothing  may  be 
protected  with  a  rubber  apron,  having 
a  hole  in  the  center  for  the  penis.  The 
irrigation  may  be  done  with  the  patient 
standing,  but  better  on  his  back,  or  sit- 
ting on  the  edge  of  a  chair  in  a  semi- 
recumbent  position  and  holding  a  basin 
in  which  to  catch  the  escaping  fluid. 
The  receptacle  containing  the  liquid 
should  be  about  two  feet  above  the 
level  of  the  penis,  though  in  some 
cases  it  may  be  raised  with  safety  to  a 
height  of  four  and  a  half  feet.  The 
solution  should  be  as  warm  as  can  be 
tolerated  with  comfort  by  the  patient, 
usually  ioo°-io5°F. 

The  patient's  bladder  being  empty, 
the  meatus,  glans,  and  anterior  urethra 
are  first  thoroughly  washed  with  a  pint 
or  more  of  the  solution.  For  irri- 
gating the  anterior  urethra  the  recep- 
tacle should  not  be  more  than  two  feet 
above  the  penis.     Either  a  smaller  nozzle,  that  will  not 

25 


Fig.  16. — Valentine's 
irrigating  apparatus. 


386      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

entirely  fill  the  urethra,  should  be  used,  or  the  larger 
nozzle  should  be  held  lightly  in  contact  with  the  meatus, 
so  as  to  allow  the  return  flow  to  escape.  A  Kiefer  noz- 
zle  (Fig.   17)   or  a   double    recurrent   catheter    may  be 


Fig.  17. — Kiefer's  urethral  irrigation  nozzle  (Tiemann). 

used,  but  is  not  essential.  Instead  of  the  short  tube  a 
soft  catheter  may  be  employed.  The  tip  should  be  intro- 
duced no  further  than  the  bulb  of  the  urethra.  When 
the  anterior  urethra  has  been  thoroughly  cleansed,  the 
nozzle  is  firmly  pressed  against  the  meatus  to  prevent 
the  escape  of  the  fluid,  which  is  thus  forced  through 
the  posterior  urethra  into  the  bladder.  If,  during  its 
passage,  the  patient  feels  a  strong  desire  to  urinate,  he 
should  be  allowed  to  empty  the  bladder,  and  the  process 
is  repeated  until  at  least  a  pint  of  the  irrigating  fluid  has 
been  used  in  the  posterior  urethra.  Irrigation  of  the 
deep  urethra  should  not  be  attempted  at  the  first  sitting, 
and  usually  not  until  the  third  or  fourth. 

In  treating  acute  gonorrhoea  by  this  method,  the 
anterior  urethra  must  be  irrigated  twice  a  day  for  four  or 
five  days,  irrigation  of  the  posterior  urethra  being  begun 
on  the  third  day.  For  another  ten  days  the  entire 
urethra  is  irrigated  daily.  When  the  discharge  recurs, 
daily  irrigations  are  again  given  for  ten  days.  The 
strength  of  the  solution  used  varies  in  different  cases, 
but  it  is  customary  to  begin  with  a  strength  of  about 
1  :  6000,  steadily  increasing  it  until  on  the  eighth  or 
tenth  day  it  is  1  :  1000  or  even  1  :  500,  after  which  the 
strength  of  the  solution  is  rapidly  diminished. 

This  method  is  both  disagreeable  and  expensive,  in 
that  it  calls  for  much  time  on  the  part  of  both  the  patient 


ACUTE    URETHRITIS.  387 

and  physician.  Moreover,  the  brilliant  results  claimed  for 
it  by  its  advocates  are  not  obtained  through  its  use  in 
the  hands  of  other  equally  skilful  operators.  In  common 
with  other  competent  observers,  we  believe  the  method 
does  not  shorten  the  course  of  gonorrhoea,  but  that,  on 
the  contrary,  it  leaves  the  mucous  membrane  of  the  ure- 
thra in  a  thickened  and  congested  condition  from  which 
it  is  slow  in  recovering ;  that  this  method  increases  the 
liability  to  epididymitis,  prostatitis,  and  other  compli- 
cations ;  and  that  in  the  hands  of  any  but  an  expert  it  is 
a  dangerous  method  of  treating  the  acute  stages  of 
urethritis. 

Finger  found  that  pure  cultures  of  the  gonococcus 
could  be  exposed  for  two  minutes  to  the  action  of 
bichloride  of  mercury  (1  :  5000),  carbolic  acid  (1  :  1000), 
potassium  permanganate  (1  :  1000),  or  nitrate  of  silver 
1  :  1000),  and  yet  grow  when  transferred  to  plate-cult- 
ures. This  being  true,  it  is  apparent  that  irrigation  as 
usually  employed  would  not  destroy  the  gonococci  in 
the  urethra,  but  would  simply  remove  such  as  were  on 
the  surface. 

The  most  promising  agent  for  the  local  treatment  of 
gonorrhoea  is  protargol.  It  has  not  been  in  use  long 
enough,  however,  to  warrant  positive  statements  regard- 
ing its  efficacy.  Solutions  of  from  1  :  600  to  I  :  100 
may  be  used  from  three  to  six  or  eight  times  daily, 
each  injection  being  retained  about  five  minutes.  After 
about  two  weeks  of  this  treatment,  mild  astringent  injec- 
tions may  be  employed.1  Solutions  containing  but  I  :  400 
are  decidedly  irritating  to  some  urethras.  Belfield  favors 
the  use  of  protargol,  as  suggested  above,  combined  with 
irrigation  with  solutions  containing  I  :  1000  each  of  pro- 
targol and  yellow  muriate  of  hydrastine. 

In  some  instances  the  intensity  of  the  inflammation 
may  be  modified  and  the  patient  made  more  comfortable 
by  the    use  of  warm  cleansing  or  anodyne  injections, 

1  The  subject  of  injections  is  considered  in  detail  under  treatment  of  the 
declining  stage. 


388      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

such  as  solutions  of  boric  acid,  borax,  or  bicarbonate  of 
sodium. 

The  following  may  be  injected  two  or  three  times  a 
day : 

Yy.  Morphin.  sulphat,  gr.  iv  ; 

Atropin.  sulphat.,  gr.  j ; 

Mucilag.  acaciae,  sij ; 

Aq.  destill.,  q.  s.  ad  |iv. — M. 

Injections  at  this  stage  must  be  used  with  the  utmost 
care  and  gentleness,  all  haste  and  pressure  being  avoided. 
In  the  large  majority  of  cases  the  symptoms  are  better 
controlled  without  the  aid  of  irrigations  or  injections. 

Local  treatment  used  at  this  period  with  a  view  to 
shortening  the  duration  of  the  disease  fails  in  its  pur- 
pose. The  substances  injected  are  either  antiparasitic  or 
astringent,  or  both.  The  parasiticide  may  destroy  some 
of  the  gonococci,  but  it  cannot  reach  many  of  them  ; 
the  astringent  may,  and  probably  does,  lessen  the  in- 
tensity of  the  inflammation  and  diminish  the  discharge, 
but  it  is  questionable  if  it  is  best  to  push  this  effect 
too  far,  as  inflammation  and  suppuration  are  nature's 
methods  of  removing  the  offending  micro-organism, 
which  as  yet  cannot  be  destroyed  by  any  more  rapid 
process.  One  cannot  hope  to  eradicate  the  disease  be- 
fore its  cause  has  been  removed.  There  is  abundant 
clinical  evidence  to  show  that  when  the  inflammation  and 
discharge  are  suppressed  by  the  use  of  injections  in  the 
early  stages  of  gonorrhoea,  the  disease  runs  a  mild  but 
protracted  course,  and  the  last  lingering  discharge  shows 
gonococci  for  a  longer  period  than  in  cases  which  have 
undergone  the  usual  two  or  three  weeks  of  acute  inflam- 
mation followed  by  a  period  of  steady  but  more  rapid  de- 
cline. Moreover,  disagreeable  and  serious  complications 
occur  much  more  frequently  in  cases  treated  by  injections 
from  the  start  than  in  cases  in  which  no  injection  is  used 
until  the  most  active  stage  of  inflammation  has  passed. 

The  danger  in  this  direction,  however,  is  possibly  not 


ACUTE    URETHRITIS.  389 

so  great  or  so  frequent  as  that  resulting  from  the  use  of 
irritating  injections  which  increase  the  inflammation  to 
such  an  extent  that  posterior  urethritis,  epididymitis, 
prostatitis,  cystitis,  or  vesiculitis  results.  These  compli- 
cations are  often  very  painful,  necessitating  the  suspen- 
sion of  all  treatment  for  the  gonorrhoea,  and  frequently 
compelling  the  patient  to  remain  in  bed  for  days  or  weeks. 
Powders  and  soluble  suppositories  are  not  to  be  con- 
sidered. They  nearly  always  do  harm.  Unless  the 
physician  has  had  large  experience  in  this  class  of  cases, 
and  has  his  patient  under  his  immediate  control,  local 
treatment  of  gonorrhoea  should  not  be  begun  until  the 
active  has  passed  into  the  subacute  stage. 

(C)  Stationary  Stage. — When  the  inflammation  has 
reached  its  acme  it  tends  to  persist  unchanged  for  about 
a  week  or  even  longer.  The  treatment  is  that  of  the 
preceding  stage,  except  that  at  this  time  the  amount  of 
copaiba  or  of  sandalwood  taken  may  be  increased.  Four 
doses  a  day  should  be  ingested,  beginning  with  about 
IO  minims  of  the  balsam  of  copaiba,  or,  if  this  is  not  well 
borne,  10  minims  of  the  oil  of  sandalwood,  and  the  dose 
should  gradually  but  steadily  be  increased  until  the 
symptoms  improve  or  until  the  stomach  will  tolerate  no 
more.  Few  can  digest  at  a  dose  more  than  20  or  30 
minims  of  either  of  these  preparations.  When  such 
quantities  have  been  given  for  a  week  without  producing 

'  favorable  results,  it  is  wise  to  change  or  to  try  a  combi- 
nation of  the  two ;  or,  if  the  discharge  continue  and  the 
inflammatory  symptoms  be  not  high,  some  preparation  of 
cubebs  may  be  added.  The  indications  for  local  treat- 
ment are  those  of  the  preceding  stage. 

(D)  Stage  of  Decline. — If  the  discharge  rapidly  subsides, 
it  is  not  wise  to  tax  the  stomach  too  severely  with  co- 
paiba or  sandalwood,  for  fear  of  having  to  suspend  their 
use  altogether ;  but  if  one  of  them  has  not  already  been 
pushed  to  the  limit,  now  is  the  time  to  do  so.  As  the 
discharge  diminishes  in  amount  and  becomes  less  puru- 
lent and  more  mucous  in  character  the  copaiba  may  be 


390      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

dropped,  and  sandalwood  oil  or  cubebs,  or  both,  be  sub- 
stituted. If  under  this  treatment  the  discharge  prac- 
tically ceases,  the  remedy  in  use  at  the  time  should  be 
continued  for  another  week  or  ten  days,  gradually  de- 
creasing the  quantity  until  at  the  end  of  the  time  the 
patient  may  be  taking  only  a  small  dose  at  night.  All 
medication  should  now  be  stopped,  and  if  at  the  end  of 
another  two  weeks  there  is  no  discharge  or  other  symp- 
tom, and  the  drop  of  mucus  squeezed  from  the  deep 
urethra  on  several  successive  days  shows  no  gonococci, 
pus  cells,  or  threads,  the  patient  may  be  allowed  to 
return  gradually  to  his  accustomed  habit  of  living.  He 
must,  however,  be  cautious  in  beginning  the  use  of  alcohol 
and  tobacco,  and  for  the  unmarried  sexual  intercourse 
promises  an  added  danger  for  some  time  to  come,  while 
the  married  must  be  careful  not  to  indulge  to  excess. 

(a)  Local  Treatment. — The  stage  of  decline  is  that 
which  is  most  frequently  prolonged,  and  it  is  here  that 
skilful  local  treatment  may  do  much  to  shorten  the 
duration  of  the  disease  and  bring  it  to  a  favorable 
termination.  As  long  as  the  discharge  contains  pus 
cells  in  considerable  numbers  local  treatment  should 
be  used — if  at  all — with  great  caution.  When,  how- 
ever, the  discharge  shows  few  or  no  pus  cells,  but 
an  increasing  number  of  epithelial  cells,  it  is  evident 
that  an  attempt  at  repair  has  begun.  The  object  of 
local  treatment  is  to  encourage  this  process  of  repair 
by  the  use  of  remedies  that  are  mildly  astringent  and 
that  will  gently  stimulate  absorption  of  the  exudate  yet 
remaining  in  the  mucous  membrane.  The  prevalent 
view  that  the  local  applications  are  intended  chiefly  to 
destroy  the  gonococci  or  pathological  tissue,  that  they 
must  be  destructive  rather  than  constructive,  is  re- 
sponsible for  much  of  the  permanent  damage  done  the 
urethra  by  too  energetic  and  too  prolonged  treatment. 
In  beginning  local  medication,  either  by  injection  or  by 
irrigation,  weak  solutions  always  should  be  tried  first. 
The  strength  can  easily  be  increased  if  found  desirable. 


ACUTE    URETHRITIS.  39 1 

Better  a  slow  but  steady  disappearance  of  the  dis- 
charge than  a  series  of  relapses  and  complications 
from  too  energetic  treatment.  Injections  and  other 
local  measures  should  always  be  reserved  as  a  last 
resort  for  a  patient  who  has  had  a  posterior  urethritis, 
an  epididymitis,  a  prostatitis,  or  a  cystitis  complicating 
his  gonorrhoea  at  any  time  during  its  course.  The 
appearance  of  one  of  these  complications  during  such 
treatment  calls  for  its  immediate  suspension. 

Local  treatment  is  used  to  greatest  advantage  when 
the  discharge  has  been  reduced  to  a  thin  muco-pus,  or 
possibly  to  a  few  drops  of  mucus  that  appear  only  in 
the  morning,  but  which  refuse  to  disappear  under  other 
treatment.  It  is  also  indicated  in  cases  of  urethritis,  of 
whatever  origin,  which  run  a  subacute  course  and  which 
do  not  respond  to  internal  treatment  and  proper  hygienic 
management.  These  statements  do  not  sanction  the  use 
of  an  injection  in  every  case  in  which  the  lips  of  the  meatus 
are  adherent  in  the  morning,  or  its  prolonged  use  in  cases 
where  a  morning  drop  or  two  at  the  meatus  will  not  dis- 
appear after  a  given  treatment  has  been  used  for  a  fort- 
night, or  in  cases  which  are  not  being  otherwise  properly 
managed.  Frequently  one  remedy  after  another  is  tried, 
the  treatment  being  persevered  in  for  weeks  with  the 
hope  of  removing  the  last  traces  of  a  discharge.  It  is 
well  to  remember  that  in  these  cases  the  irritation  may 
be  kept  up  by  the  treatment,  cessation  of  which  being 
followed  often  by  prompt  recovery. 

Injections  which  the  patient  can  use  himself  furnish 
the  most  convenient  local  treatment  for  the  anterior  ure- 
thra. To  inject  the  urethra  properly  calls  for  the  right 
kind  of  a  syringe  and  some  skill  on  the  part  of  the  patient, 
easily  acquired  by  the  majority.  The  syringe  should  hold 
3  or  4  drachms,  though  the  urethra  usually  will  hold 
less  than  two.  The  piston  should  fit  tightly,  to  permit 
no  leaking,  but  at  the  same  time  should  move  freely  and 
easily  within  the  barrel,  and  should  have  a  ring  at  the 
end  to  receive  the  index  finger.     The  nozzle  should  be 


392      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

a  blunt  cone,  so  that  the  tip,  which  should  be  perfectly 
smooth,  will  barely  enter  the  meatus,  and  will  not  pro- 
ject into  the  urethra  to  irritate  or  damage  the  mucous 
membrane  (Fig.   18).     The  syringe  having  a  barrel  of 


Fig.  iS. — Urethral  syringe. 

hard  rubber  with  a  soft-rubber  tip  fulfils  these  require- 
ments admirably.  It  is  perhaps  needless  to  add  that 
the  syringe   should  be  scrupulously  clean. 

To  inject  successfully,  the  patient  should  encircle  the 
penis,  just  back  of  the  corona,  with  the  thumb  and  the 
forefinger  of  the  left  hand,  exerting  no  more  pressure 
than  is  necessary  to  enable  him  to  extend  the  organ  to 
its  full  length  as  the  fluid  is  forced  in.  The  syringe 
should  be  held  in  the  right  hand,  with  the  tip  of  the 
index  finger  in  the  ring  at  the  end  of  the  piston,  while 
the  barrel  is  firmly  held  between  the  other  three  fingers 
and  the  thumb.  With  the  penis  gently  drawn  out  to  its 
full  length,  and  with  the  tip  of  the  syringe  pressing  into 
the  meatus  with  just  sufficient  firmness  to  prevent  leak- 
age, the  fluid  is  slowly  and  steadily  forced  in  until  a  slight 
ballooning  or  a  feeling  of  fulness  and  tension  in  the  urethra 
informs  the  patient  that  the  urethra  will  hold  no  more. 
As  the  syringe  is  withdrawn  the  lips  of  the  meatus  are 
gently  held  together,  retaining  the  medicament  in  the 
urethra  for  about  a  minute  before  allowing  it  to  escape. 
The  whole  procedure  should  be  gentle ;  any  forcing  of 
the  fluid  back  of  the  compressor  urethrae  muscle  into  the 
deep  urethra  and  the  bladder  is  to  be  avoided.  Slight 
pressure  upon  the  piston  is  not  dangerous,  and  no  more 
is  necessary.  Injections  may  be  used  once,  twice,  or 
three  times  a  day  (occasionally  more  frequently),  the 
last  on  retiring  for  the  night ;  but,  should  an  injection 
cause  burning  or  pain,  it  must  be  allowed  to  escape  at 
once,  and  before  it  is  employed  again  the  fluid  must  be 


ACUTE    URETHRITIS.  393 

diluted  largely.     The  patient  should  always  first  urinate, 
thus  cleansing  the  urethra  before  each  injection. 

Substances  almost  innumerable  have  been  recom- 
mended and  employed  for  urethral  injections,  but  the 
skilful  physician  will  select  a  few,  usually  not  more  than 
two  or  three,  and  learn  to  use  them  well.  He  becomes 
thoroughly  familiar  with  their  effects  upon  the  varying 
stages  and  conditions  of  urethral  inflammation,  and 
accomplishes  better  and  more  definite  results  if  he  uses 
these  few  remedies,  in  varying  strength  and  frequency 
of  application,  than  if  he  resort  to  others  excellent  in 
themselves,  but  with  which  he  is  less  familiar.  As 
has  already  been  stated,  the  effect  desired  is  that  of  a 
mild  astringent  and  slight  stimulant  to  absorption. 
Among  the  remedies  which  fill  these  requirements  best 
are  nitrate  of  silver,  i  :  15,000  to  1  :  1000;  protargol, 
I  :  800  to  1  :  100;  zinc  sulphate,  acetate,  or  sulpho- 
carbolate,  1  :  1 000  to  1  :  100;  potassium  permanganate, 
1  :  4000  to  1  :  500;  and  muriate  of  hydrastis,  I  :  500  to 
1  :  100.  From  5  to  10  per  cent,  of  glycerine  may  often 
be  added  to  an  injection  with  good  results.  For  an 
anodyne  effect,  some  preparation  of  opium,  belladonna, 
or  hyoscyamus  may  be  added.  The  following  formulae 
are  useful : 

Ify.  Liq.  plumbi  subacetatis  dil.,        3j ; 

Morphias  acetatis,  gr.  j. — M. 

This  formula  is  recommened  by  Keyes  for  use  in  lesser 
stages  ot  inflammation. 

I$s.  Morph.  sulphat,  gr.  iv-xij ; 

Plumbi  acetat,  gr.  iv-viij ; 

Bismuth,  subnitrat,  3j-ij ; 

Glycerin.,  3j_jj ; 

Aq.  destill.,  q.  s.  ad  5iv.— M. 

Shake  well  before  using. 


Or, 


ty.  Zinci  sulphat,  gr.  j-ij  ; 

Aq.  destill.,  gj. — M. 


394      SYPHILIS  AND    THE  VENEREAL  DLSEASES. 

Or, 

T*y.  Zinci  sulphat., 

Plumbi  acetat,  da  gr.  iv-viij ; 

Glycerin,  3j— iij  ; 

Aq.  destill,  q.  s.  ad  §iv. — M. 

In  ordering  an  injection  it  is  well  to  advise  at  first  a 
dilution  with  two  or  three  times  its  bulk  of  water;  if 
this  be  ineffectual,  and  yet  produce  no  irritation,  the 
strength  may  gradually  be  increased.  On  the  contrary, 
no  injection  should  be  continued  which  causes  more 
than  a  slight  smarting  sensation  while  in  the  urethra  and 
possibly  for  a  few  minutes  afterward.  The  idea  of 
"  cauterizing  "  the  urethra  or  "  burning  out  "  the  disease 
has  long  since  been  abandoned.1 

Irrigation  in  some  form  usually  gives  good  results  if 
the  deep  urethra  be  involved.  The  best  method  is  that 
described  in  the  preceding  pages  as  "  Janet's  Method."  In 
patients  who  cannot  learn  to  relax  the  cut-off  muscle,  the 
soft  catheter  may  be  used  as  directed  in  the  chapter  on 
Chronic  Urethritis.  The  solutions  of  most  value  for  use 
in  the  deep  urethra  in  order  of  preference  are  nitrate  of  sil- 
ver, i  :  20,000  to  1  :  5000;  permanganate  of  potash,  1  : 
10,000  to  1  :  2000 ;  and  bichloride  of  mercury,  1  :  60,000 
to  1  :  20,000.  Protargol  solutions  (1  :  1000)  have  given 
excellent  results  in  a  few  cases.  Weak  solutions  of 
alum  and  zinc  sulphate  (1  :  2000  to  I  :  500)  are  preferred 
by  Taylor  and  others  to  all  remedies  except  nitrate 
of  silver.  The  irrigations  begin  with  the  weaker  solu- 
tions, which  may  slowly  be  increased,  if  necessary  to 
produce  the  desired  effect,  and  at  first  should  not  be 
given  oftener  than  every  second  or  third  day,  so  that 
the  effect  of  the  treatment  may  be  observed.  In  the 
meantime  an  injection  of  the  same  remedy  in  somewhat 
stronger  solution,  or  of  some  other  preparation,  may  be 
used  in  the  anterior  urethra  by  the  patient. 

It    the   treatment    produces    increased    irritation    and 

1  Injections  are  further  considered  in  connection  with  the  treatment  of 
Chronic  Urethritis. 


ACUTE    URETHRITIS.  395 

suppuration,  it  should  be  stopped  at  once  and  milder 
measures  or  other  remedies  tried.  If,  on  the  other 
hand,  the  symptoms  improve,  and  the  urine,  examined 
by  methods  explained  in  connection  with  the  diagnosis 
of  chronic  urethritis,  shows  a  steadily  diminishing  quan- 
tity of  pus  and  mucus,  the  treatment  should  be  con- 
tinued until  the  urine  is  almost  or  quite  clear.  It  is 
always  well  at  the  end  of  ten  days  or  two  weeks  to 
suspend  treatment  for  a  few  days  to  ascertain  what  has 
been  accomplished.  Such  a  pause  is  often  followed  by 
complete  clearing  of  the  urine,  and  the  danger  of  con- 
tinuing the  congestion  by  too  much  treatment  is  avoided. 

The  practitioner  should  never  forget  his  patient  while 
treating  his  patient's  urethra.  A  feeble  or  cachectic  sub- 
ject should  not  have  a  restricted  diet  that  may  still  fur- 
ther reduce  his  strength  and  vitality.  A  man  with  a 
weak  stomach  should  not  swallow  medicaments  that 
induce  marked  digestive  disturbances.  No  physician 
should  persist  in  directing  his  efforts  solely  to  the 
urethral  discharge  when  the  general  condition  of  the 
patient  calls  for  tonic  or  specific  treatment.  Sometimes 
a  subacute  urethritis  in  a  feeble  or  cachectic  individual 
refuses  to  subside  under  treatment  ordinarily  indicated 
in  a  urethritis  of  the  same  grade  and  character,  but 
improves  rapidly  and  disappears  after  the  administration 
of  iron,  quinine,  strychnine,  cod-liver  oil,  or  malt, 
together  with  fresh  air  and  sunshine — in  short,  under 
such  treatment  as  is  called  for  by  the  general  condition. 

Prognosis. — The  first  attack  of  gonorrhoea,  under 
proper  management  and  in  a  healthy  man,  has  a  ten- 
dency to  run  a  definite  course  toward  recovery.  It  is 
quite  unusual,  however,  for  a  patient  with  gonorrhoea 
to  be  so  situated  that  all  his  surroundings  are  favorable 
to  his  complete  recovery.  Such  a  situation  is  difficult 
to  obtain  for  any  but  those  who  for  some  other  reason 
are  compelled  to  remain  in  bed  during  the  course  of  the 
disease ;  and,  as  each  successive  attack  exhibits  a  greater 
tendency  to  become  chronic  or  to  leave  some  portion  of 


396      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

the  urethra  permanently  damaged,  the  consequence  is  that 
but  few  urethras  once  infected  with  gonorrhoea  ever  re- 
turn fully  to  their  normal  condition.  Noeggerath  be- 
lieves that  a  man  never  fully  recovers  from  his  first 
gonorrhoea,  and  claims  that  nine-tenths  of  all  women 
married  to  men  who  have  ever  had  gonorrhoea  eventu- 
ally become  sufferers  from  some  form  of  pelvic  inflam- 
mation. This  is  an  extreme  view,  and  one  not  generally 
accepted.  It  is,  however,  not  safe  for  a  man  to  resume 
sexual  relations  within  six  months  after  his  acute  gonor- 
rhoea is  apparently  well,  unless  he  has  been  subjected  to 
proper  tests.  The  question  is  further  considered  under 
the  head  of  the  Infectiousness  of  Chronic  Gonorrh&a. 

The  duration  of  a  gonorrhoea  under  proper  treatment 
depends  so  much  upon  the  individual,  his  habits,  his 
surroundings,  and  the  previous  state  of  his  urethra,  that 
it  is  impossible  to  make  definite  statements  applicable 
to  all  cases.  The  prognosis  must  always  be  guarded. 
Usually  the  first  attack  of  gonorrhoea,  under  favorable 
circumstances  and  with  good  treatment,  lasts  from  five 
to  eight  weeks.  The  discharge  may  disappear  or  be 
suppressed  by  local  treatment  much  earlier,  but  this  fact 
by  no  means  proves  that  the  urethra  is  in  a  healthy 
condition  or  that  slight  irritation  may  not  induce  a  dis- 
charge showing  gonococci  in  abundance  and  proving 
highly  infectious.  Successive  attacks,  though  less  acute, 
are  generally  of  longer  duration.  In  general,  an  attack 
following  a  short  period  of  incubation,  in  which  the 
symptoms  rapidly  reach  a  climax  of  intensity,  terminates 
in  recovery  earlier  than  another  with  a  longer  period  of 
incubation  in  which  the  symptoms  are  subacute. 

The  immediate  and  remote  results  of  gonorrhoea  upon 
other  organs  of  the  body  and  upon  the  general  health 
have  been  mentioned  at  the  beginning  of  this  chapter, 
and  are  further  considered  under  the  complications  of 
urethritis. 


ACUTE   POSTERIOR    URETHRITIS.  397 

ACUTE    POSTERIOR   URETHRITIS. 

The  term  "  acute  posterior  urethritis  "  is  applied  to 
inflammation  of  the  membranous  and  prostatic  portions 
of  the  urethra.  The  compressor  urethrae  muscle  forms 
the  dividing-line  between  the  two  anatomical  divisions 
of  the  urethra,  known  as  the  anterior  and  posterior 
(or  deep)  urethra,  or  the  pars  anterior  and  the  pars 
posterior.  The  pars  anterior  includes  the  bulbous  and 
pendulous  portions  of  the  urethra ;  the  pars  posterior, 
the  prostatic  and  membranous  portions.  The  division 
is  of  importance  from  a  pathological  point  of  view, 
because  of  the  close  anatomical  relations  between  the 
posterior  urethra  and  the  epididymis,  prostate,  bladder, 
and  seminal  vesicles.  Inflammation  of  any  of  these 
organs  is  liable  to  occur  with  or  after  posterior  urethritis, 
and  when  one  of  them  is  implicated  the  presence  of 
posterior  urethritis  may  be  taken  for  granted. 

Posterior  urethritis  occurs  in  probably  a  majority  of 
all  cases  of  gonorrhoea,  and  is  undoubtedly  due  to 
a  simple  extension  of  the  infection  along  the  mucous 
membrane.  The  condition,  however,  is  especially  fre- 
quent and  severe  in  cases  subjected  to  improper  local 
treatment,  or  which  have  not  had  proper  hygienic  man- 
agement, or  in  cachectic  and  debilitated  individuals.  At 
any  time  during  the  course  of  gonorrhoea  the  extension 
of  the  inflammation  to  the  pars  posterior  is  favored  by 
any  mode  of  living  or  treatment  that  tends  to  congest 
or  irritate  this  portion  of  the  urethra.  As  a  result  of 
accident,  or  of  injury  from  instruments,  deep  injections, 
highly  acid  urine,  or  fragments  of  calculi,  posterior 
urethritis  may  appear  independently  of  inflammation  of 
the  pars  anterior. 

Symptoms. — The  symptoms  may  be  so  mild  as  to 
escape  the  attention  of  the  patient ;  hence  it  is  difficult  to 
say  just  when  the  condition  begins.  In  the  majority  of 
cases,  however,  there  is  increased  frequency  of  uri- 
nation, with  pain  and  burning  in  this  part  of  the  urethra, 


398      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

especially  after  urination.  There  is  commonly  some 
feeling  of  pressure,  weight,  or  discomfort,  with  possi- 
bly burning  or  mild  pains  in  the  perineum.  Some 
sexual  irritation  is  noticeable  in  practically  all  cases. 
Posterior  urethritis  is  sometimes  announced  by  a  more 
or  less  sudden  increase  in  the  frequency  of  urination,  the 
patient  sometimes  being  compelled  to  urinate  every  few 
minutes  from  the  beginning  of  the  attack.  At  the  same 
time  the  process  in  the  anterior  portion  often  subsides  to 
a  great  extent,  with  marked  diminution  in  the  discharge 
from  the  meatus  ;  and  though  the  reverse  may  be  true( 
yet  the  sudden  cessation  of  a  gonorrhceal  discharge  should 
always  lead  one  to  suspect  this  complication.  In  severe 
cases  the  inflamed  mucous  membrane  of  the  prostatic 
urethra  becomes  so  sensitive  and  irritable  that  it  will  not 
tolerate  the  presence  of  the  smallest  amount  of  urine  in 
the  bladder,  and  but  a  few  drops  are  required  to  excite 
an  uncontrollable  desire  to  urinate,  the  tenesmus  often 
being  excruciatingly  painful.  In  other  instances  the 
patient  has  such  poor  control  of  this  inflamed  outlet  of 
the  bladder,  or  the  desire  to  urinate  comes  on  at  irregular 
intervals  and  so  suddenly  and  with  such  severe  pain, 
that  the  urine  escapes  before  he  can  reach  a  urinal.  In 
still  other  cases  there  may  be  complete  retention  of  urine. 

A  few  drops  of  blood  may  appear  at  the  close  of  each 
urination,  or  the  hemorrhage  may  be  considerable — some- 
times sufficient  to  pass  backward  into  the  bladder  and  to 
color  all  the  urine.  The  perineum  may  be  the  seat  of 
severe  burning  or  cutting  pains  which  may  radiate  to  the 
end  of  the  penis,  to  the  testicles,  the  groins,  or  the  back. 
There  is  usually  considerable  irritation  of  the  sexual 
organs,  manifested  in  prolonged  and  painful  erections  at 
night,  and  in  frequent  seminal  emissions,  which  may  be 
mixed  with  blood. 

The  acute  symptoms  in  a  posterior  urethritis  may  last 
from  a  few  days  to  several  weeks,  but  the  process  is  often 
prolonged  in  a  subacute  form  and  shows  a  decided  ten- 
dency to  become  chronic.      In   the   severest  cases  the 


ACUTE   POSTERIOR    URETHRITIS.  399 

sufferings  of  the  patient  from  pain  and  lack  of  rest  are 
extremely  pitiful.  When  posterior  urethritis  compli- 
cates an  old  stricture  or  hypertrophied  prostate,  the 
condition  is  a  very  serious  one.  Fortunately,  in  most 
instances  the  disease  runs  a  mild  or  but  moderately 
severe  course.  The  danger  of  further  complications, 
such  as  prostatitis,  epididymitis,  etc.,  should,  however, 
be  kept  in  mind. 

Diagnosis. — The  occurrence,  during  gonorrhoea,  of 
frequency  of  urination,  tenesmus,  hemorrhage,  or  the 
sudden  cessation  of  the  discharge,  should  lead  one  to 
examine  for  posterior  urethritis.  The  finger  in  the  rec- 
tum finds  the  prostatic  and  membranous  portions  of  the 
urethra  sensitive ;  slight  pressure  increases  the  pain  and 
tenesmus,  but  the  prostate  is  not  enlarged.  Examina- 
tion with  instruments  in  the  urethra  is  contraindicated, 
but  the  urine  should  be  examined  carefully  by  Thomp- 
son's two-glass  test.  This  test  is  based  on  the  supposi- 
tion that  pus  secreted  in  the  prostatic  urethra  cannot 
pass  the  compressor  urethras  muscle  and  find  its  way 
out  through  the  pendulous  portion;  but,  on  the  contrary, 
if  more  pus  collects  than  the  prostatic  urethra  can  hold, 
it  will  pass  back  into  the  bladder  and  mingle  with  the 
urine,  rendering  the  latter  cloudy.  If  the  patient  passes 
the  contents  of  his  bladder  in  two  glasses,  the  first  glass 
will  contain  urine  plus  the  washings  of  the  urethra, 
while  the  second  will  contain  the  urine  as  it  exists  in  the 
bladder.  If  this  second  portion  is  clouded  by  the 
presence  of  pus,  the  latter  evidently  comes  from  some 
portion  of  the  genito-urinary  tract  back  of  the  compres- 
sor urethras  muscle. 

The  exact  localization  of  the  source  of  pus  in 
the  bladder  is  often  difficult  and  calls  for  careful 
microscopical  examination,  but  the  presence,  during 
the  course  of  gonorrhoea,  of  pus  in  the  second  glass, 
together  with  the  occurrence  of  the  above-described 
symptoms,  will  point  strongly  to  posterior  urethritis. 
If  the   urine   is   passed   frequently,  there   may  be  times 


400      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

when  no  more  pus  will  accumulate  than  the  prostatic 
urethra  can  hold  (when  it  will  all  be  washed  out  with 
the  first  urine),  so  that  the  urine  inihe  bladder  will  re- 
main clear  and  will  appear  so  in  the  second  glass.  This 
occasional  appearance  of  clear  urine  in  the  second  glass 
will  exclude  cystitis.  In  less  acute  cases,  since  the 
amount  of  pus  produced  is  small,  the  urine  in  the  second 
glass  may  always  be  clear  unless  the  urine  has  been  re- 
tained in  the  bladder  three  or  four  hours.  It  is  import- 
ant, consequently,  that  the  morning  urine — also  that 
passed  at  the  time  of  the  visit — be  examined.  The 
degree  of  cloudiness  and  the  amount  of  pus  in  the  urine 
of  the  second  glass  give  some  indication  of  the  intensity 
of  the  inflammation.1  More  accurate  use  of  the  two- 
glass  tests  may  be  made  by  first  carefully  and  thoroughly 
irrigating  the  anterior  urethra  with  a  warm  solution  of 
boric  acid.  The  first  glass  will  then  contain  pus  from 
the  posterior  urethra  only,  in  case  that  portion  of  the 
canal  is  involved.  If  the  amount  of  pus  is  small,  it  should 
be  thrown  down  with  a  centrifuge  and  examined  while 
fresh. 

Treatment. — The  general  hygienic  management  is 
that  of  gonorrhoea,  except  that  rest  is  of  still  greater 
importance,  and  in  severe  cases  with  much  tenesmus  or 
hemorrhage  rest  in  bed,  or  at  least  in  the  recumbent 
position,  is  absolutely  necessary.  Large  quantities  of 
bland  fluids,  such  as  flaxseed  or  slippery-elm  tea,  should 
be  drunk,  and  the  urine  should  be  rendered  sterile  by 
the  use  of  boric  acid,  salol,  or  salicylate  of  sodium,  in 
doses  of  from  5  to  10  grains  four  times  a  day.  Free  dilu- 
tion of  the  urine  is  preferable  to  the  use  of  alkalies,  which 
may  increase  the   danger  of  ammoniacal  decomposition 

1  The  only  cloudiness  of  urine  considered  in  these  pages  is  that  pro- 
duced by  pus  and  mucus.  The  nature  of  the  sediment  in  any  specimen 
of  turbid  urine  should  be  determined  by  the  usual  methods  of  urinalysis  or 
microscopical  examination.  Gentle  heat  clears  a  turbidity  due  to  the 
presence  of  urates;  acetic  acid,  that  caused  by  phosphates  or  carbonates; 
bacteria  and  pus  can  be  removed  only  by  filtration. 


ACUTE   POSTERIOR    URETHRITIS.  401 

in  the  bladder.  Such  decomposition  and  the  pus  infec- 
tion of  the  bladder,  which  is  frequently  present,  can 
usually  be  controlled  by  the  use  of  urotropin,  in  doses  of 
from  3  to  8  grains  four  times  a  day.  Copaiba  and  san- 
dalwood are  valuable  in  many  cases,  but  they  may  prove 
irritating,  and  should  then  be  stopped.  If  the  urine  is 
markedly  alkaline  and  contains  pus,  it  may  be  advisable 
to  g-ive  benzoate  of  ammonium  in  small  doses  sufficient 
to  keep  the  urine  neutral,  but  if  given  too  freely  it  will 
prove  a  source  of  irritation. 

For  the  purpose  of  controlling  the  pain  and  tenesmus, 
suppositories  containing  morphine  (gr.  3^)  and  atropine 
(gr.  -^q)  may  be  used  in  the  rectum,  or  from  I  to  10 
minims  of  the  fluid  extract  of  hyoscyamus  may  be  given 
every  few  hours.  The  use  of  a  catheter  is  to  be  avoided 
if  possible,  and  is  rarely  necessary  if  the  directions 
given  for  the  treatment  of  retention  of  urine  in  gonor- 
rhoea be  faithfully  followed.  Allowing  the  patient  to 
urinate  while  sitting  in  a  tub  of  hot  water  will  rarely  fail 
to  give  better  results  than  the  catheter.  If  the  posterior 
urethritis  has  come  on  during  the  declining  stage  of 
gonorrhoea,  or  if  for  any  reason  local  treatment  of  the 
anterior  urethra  has  been  instituted,  such  treatment  must 
be  suspended  at  once.  Local  treatment  should  not  be 
undertaken  until  the  acute  symptoms  have  subsided. 
The  methods  to  be  employed  are  described  under  treat- 
ment of  the  declining  stage  of  gonorrhoea. 

26 


CHRONIC  URETHRITIS. 


Synonyms. — Chronic  gonorrhoea ;  Gleet. 

Before  terminating  in  complete  recovery  every  case 
of  acute  urethritis  passes  through  a  subacute  stage  with 
a  muco-purulent  and  finally  a  mucous  discharge.  Fol- 
lowing a  first  attack  of  gonorrhoea,  in  a  healthy  man 
under  favorable  hygienic  surroundings,  this  muco-puru- 
lent stage  tends  to  recovery  without  local  treatment ; 
but  when  following  repeated  infections,  or  an  infection  in 
an  unhealthy  individual  or  in  one  subjected  to  improper 
treatment  or  other  injurious  influences,  this  subacute 
stage  may  be  prolonged  indefinitely,  as  a  chronic  ure- 
thritis, known  in  popular  parlance  as  "  gleet." 

Etiology. — Chronic  urethritis  originates  usually  in 
gonorrhoea  or  other  form  of  acute  urethritis,  but  in  the 
cachectic  it  may  occur  independently  of  an  acute  attack. 

The  influences  which  interfere  with  the  proper  re- 
covery of  gonorrhoea  and  which  tend  to  prolong  the  dis- 
ease in  chronic  form  are  numerous  and  vary  widely  in 
different  individuals.  The  general  health  of  the  patient 
is  an  important  factor.  In  gouty,  rheumatic,  strumous, 
syphilitic,  tubercular,  anaemic,  or  debilitated  persons  it  is 
not  unusual  for  gonorrhoea  to  be  followed  by  chronic 
urethritis.  It  occurs  frequently  as  a  result  of  repeated 
infections,  or  after  a  first  infection  in  which  there  have 
been  a  series  of  relapses. 

Probably  the  chief  factors  in  the  production  of  chronic 
urethritis  lie  in  the  failure  of  the  patient  to  observe  a 
proper  sexual  hygiene  during  and  after  an  attack  of  gon- 
orrhoea ;  and  the  most  persistent  and  intractable  cases 
are  found  in  men  who,  in  spite  of  their  disease,  are  in- 
dulging  in   promiscuous    sexual    relations,   or   who   are 

402 


CHRONIC   URETHRITIS.  403 

subjecting  themselves  to  other  forms  of  sexual  excite- 
ment, or  who,  in  their  efforts  to  get  well,  are  constantly 
irritating  the  urethra  by  improper  or  excessive  treat- 
ment. Mention  has  already  been  made  of  the  fact  that 
the  cessation  of  a  urethral  discharge  does  not  necessarily 
mean  that  the  urethra  has  returned  to  a  normal  condi- 
tion. It  is  difficult  to  make  the  average  patient  under- 
stand this  fact,  and  realize  the  necessity  of  his  living 
hygienically  for  some  weeks  or  months  after  his  gonor- 
rhoea is  apparently  cured.  Offenders  of  one  class  resume 
sexual  relations  as  soon  as  the  discharge  becomes  in- 
visible. Such  men  often  incur  fresh  infection,  and  have 
within  a  few  months  a  series  of  gonorrhoeas  some  one  of 
which  will  surely  terminate  in  the  chronic  form  ;  or,  if 
fortunate  enough  to  escape  fresh  gonorrhoeal  infection, 
nevertheless  the  recently  inflamed  mucous  membrane  of 
the  urethra  becomes  the  seat  of  small  areas  of  chronic 
congestion  and  infiltration,  resulting  in  a  gleety  dis- 
charge. Others,  without  sexual  intercourse,  indulge  in 
sexual  excitement,  physical  or  mental,  which  aggravates 
the  congestion  of  the  parts  and  does  not  permit  the  rest 
necessary  for  a  complete  recovery. 

Alcohol  and  tobacco  are  irritants  to  the  mucous  mem- 
brane of  the  urethra,  and  if  used  during  the  course  of  gon- 
orrhoea or  urethritis  tend  to  prolong  the  disease.  The 
resumption  of  their  use  too  soon  after  the  apparent  cure 
of  an  inflammation  of  the  urethra  is  many  times  responsi- 
ble for  a  return  of  the  discharge ;  while  many  subacute 
cases  refuse  to  get  well  until  the  patient  abandons  his 
habits  in  this  particular.  Similar  in  effect  to  the  use  of 
alcohol  and  tobacco,  though  in  lesser  degree,  are  excesses 
in  eating,  especially  of  nitrogenous  and  highly  seasoned 
foods.  Imperfect  digestion,  followed  by  incomplete  as- 
similation and  metabolism,  necessitates  the  elimination 
through  the  urine  of  products  foreign  to  normal  urine, 
and  therefore  irritating  to  the  urethral  mucous  membrane. 
Imperfect  functional  activity  of  the  skin  and  the  bowels, 
by  adding  to  the  quantity  of  solids  in  the  urine,  and  there- 


404      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

fore  to  its  irritating  qualities,  may  retard  the  recover}-  of 
a  urethritis.  Excessive  physical  exercise,  while  not  so 
harmful  as  in  acute  urethritis,  sometimes  exerts  a  dele- 
terious influence  upon  a  chronic  discharge. 

A  frequent  source  of  chronic  urethritis  lies  in  exces- 
sive and  ill-advised  treatment,  the  patient  trying  one  in- 
jection after  another,  using  sounds,  soluble  bougies,  and 
other  forms  of  local  and  internal  treatment,  in  hopes  of 
removing  the  last  trace  of  his  discharge.  These  cases 
are  most  frequently  found  in  unmarried  men  who  are 
greatly  worried  about  themselves  and  who  drift  from 
one  physician  to  another.  They  try  the  "  infallible " 
prescriptions  recommended  by  their  friends,  and  in  the 
course  of  their  wanderings  they  sooner  or  later  fall  into 
the  hands  of  charlatans,  and  submit  to  all  sorts  of  opera- 
tions and  treatment.  If  properly  advised  in  time,  before 
operative  procedures  have  damaged  the  tissues,  many  of 
these  cases  recover  completely  as  a  result  of  simply  sus- 
pending all  treatment  and  living  hygienicaliy.  The 
habit  which  many  of  these  patients  have  of  trying 
several  times  a  day  to  squeeze  out  a  drop  of  mucus 
from  the  urethra,  for  the  purpose  of  ascertaining  the 
progress  of  the  disorder,  is  often  the  sole  cause  of  the 
mucous  discharge.  The  frequent  squeezing  and  bruising 
of  the  membrane  keep  it  irritated  and  congested. 

When  the  mucous  or  muco-purulent  stage  has  lasted 
for  some  weeks,  or  when  there  has  been  a  series  of  re- 
lapses, the  disease  usually  becomes  localized.  The 
greater  portion  of  the  urethral  mucous  membrane  re- 
covers its  normal  condition,  but  certain  circumscribed 
areas  become  the  seat  of  chronic  congestion  and  infiltra- 
tion, or  some  of  the  complications  which  have  arisen 
become  persistent.  The  causes  of  this  localization  lie 
largely  in  the  anatomical  structure  of  the  different  parts 
of  the  genito-urinary  tract.  The  inflammatory  process 
naturally  becomes  more  firmly  seated  in  those  portions 
well  supplied  with  follicles,  glands,  and  vessels.  For 
this   reason   the   prostatic  and   bulbous   portions  of  the 


CHRONIC   URETHRITIS.  405 

urethra  and  the  fossa  navicularis  are  especially  liable  to 
the  persistent  forms  of  inflammation  and  congestion. 
In  many  cases  chronic  inflammation  of  the  glands  of 
Littre,  the  crypts  of  Morgagni,  or  some  of  the  large 
follicles  in  the  pendulous  portion  of  the  urethra  are 
responsible  for  the  persistence  of  a  slight  mucilaginous 
discharge. 

Among  the  local  conditions  which  may  exert  an  un- 
favorable influence  upon  chronic  urethritis  or  be  respon- 
sible for  its  persistence  are  areas  of  congestion  and  in- 
filtration in  the  urethra,  stricture,  hypertrophy  of  the 
prostate,  prostatitis,  vesiculitis,  lacunal  inflammation, 
Cowperitis,  folliculitis,  periurethral  abscess,  fistulae  with 
internal  openings,  mucous  patches  in  the  urethra,  and 
local  tuberculosis. 

The  role  of  the  gonococcus  in  the  etiology  of  chronic 
urethritis  is  not  yet  definitely  determined.  These  micro- 
organisms can  be  demonstrated  in  many  cases,  but  they 
are  present  in  small  numbers,  and  often  can  be  found 
only  after  repeated  examinations ;  while  in  quite  a  per- 
centage of  cases  repeated  careful  examinations  fail  to 
show  the  gonococci.  It  would  seem  that  the  patho- 
logical processes  instituted  by  the  gonococcus  may  con- 
tinue after  the  disappearance  of  the  latter.  Some  of  the 
changes  are  probably  due  to  the  action  of  other  micro- 
organisms, as  it  is  generally  conceded  that  gonorrhoea  is 
frequently  a  mixed  infection. 

Symptoms. — The  symptoms  of  chronic  urethritis  vary 
with  the  individual,  the  duration  of  the  disease,  and  its 
location.  In  recent  cases  and  in  those  undergoing 
active  local  treatment  there  is  usually,  in  addition  to  the 
circumscribed  pathological  process,  more  or  less  conges- 
tion and  catarrhal  condition  of  the  mucous  membrane 
of  the  entire  urethra,  resulting  in  a  mucous  discharge 
which  may  be  sufficient  to  stain  the  linen,  or,  if  the  pre- 
puce be  long,  to  keep  its  inner  surface  and  that  of  the 
glans  constantly  moist ;  or  there  may  be  a  subacute  in- 
flammation with  a  muco-purulent  discharge. 


406      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

In  old  cases  in  which  most  of  the  urethral  mucous  mem- 
brane is  healthy  and  the  disease  is  confined  to  one  or  more 
small  areas,  two  or  three  drops  of  mucus  or  of  muco- 
pus  collect  in  the  urethra  during  the  night  and  are  seen 
at  the  meatus  by  the  patient  on  rising  in  the  morning. 
During  the  day,  when  the  urethra  is  washed  out  more 
frequently  by  the  passage  of  urine,  the  collection  is 
usually  only  sufficient  to  cause  slight  moisture  of  the 
lips  of  the  meatus  or  to  slightly  glue  them  together ;  or 
there  may  be  no  evidence  of  discharge  during  the  day, 
and  but  an  occasional  agglutination  of  the  lips  of  the 
meatus  in  the  morning ;  or,  finally,  there  may  be  no 
symptoms  noticeable  by  the  patient  while  he  is  living  a 
regular  life,  though  sexual  indulgence  or  the  use  of 
alcohol  or  tobacco,  or  even  excesses  in  eating  or  in  ex- 
ercising, may  cause  a  prompt  return  of  the  discharge. 
These  relapses  are  frequently  considered  new,  mild  in- 
fections, but  they  differ  from  the  latter  in  that  the  symp- 
toms appear  at  once,  without  any  period  of  incubation, 
and  subside  in  a  few  days  under  simple  treatment. 
Sometimes  the  only  evidence  of  disease  is  that  found  in 
the  urine,  which  may  be  clouded  with  pus  and  mucus 
from  the  posterior  urethra,  or  may  be  clear  except  for 
shreds  composed  of  mucus,  epithelium,  and    pus-cells. 

Subjective  sensations  are  often  entirely  wanting, 
though  the  condition  may  persist  for  months  or  years. 
More  frequently  the  patient  experiences,  while  urinat- 
ing, slight  burning,  pricking,  or  tingling  sensations 
along-  the  urethra  or  at  the  site  of  the  lesions.  In 
disease  of  the  posterior  urethra  there  may  be  a  feeling 
of  warmth,  fulness  or  weight  in  the  perineum,  with  pos- 
sibly some  increased  frequency  of  urination,  or  even 
slight  tenesmus  ;  and  if,  as  frequently  happens,  the  in- 
flammation invades  the  glands  and  the  tissues  of  the 
prostate,  there  may  be  added  all  the  distressing  symp- 
toms, both  physical  and  mental,  of  chronic  prostatitis. 

If  the  process  extends  beneath  the  mucous  membrane 
of  the  urethra,  stricture  may  follow,  with  all  its  symp- 


CHRONIC   URETHRITIS.  407 

toms.  If  one  or  more  follicles  or  glands  of  the  urethra 
or  the  periurethral  tissues  are  involved,  the  symptoms 
will  depend  upon  the  activity  of  the  inflammation  in 
these  structures. 

Pathology. — Regarding  the  pathology  of  chronic 
urethritis,  Finger,  who  has  made  a  histological  study 
of  a  large  number  of  cases,  arrives  at  the  following 
conclusions : 

"  1.  Chronic  urethritis  is  a  focal  process  which  runs 
its  course  as  a  chronic  hyperplasia  in  the  subepithelial 
connective  tissue.  Disease  of  the  epithelium  and  glands 
is  to  be  regarded  in  part  as  a  complication,  in  part  as  a 
sequel. 

"  2.  The  foci  of  chronic  blennorrhcea  are  localized 
preferably  in  the  pendulous  portion,  the  bulb,  and  the 
prostatic  portion. 

"  3.  The  membranous  portion  is  relatively  immune  to 
the  chronic  process. 

"4.  In  a  series  of  cases  the  foci  of  chronic  inflamma- 
tion in  the  pars  anterior  and  posterior  are  situated  super- 
ficially in  the  mucous  and  subepithelial  connective  tissue. 

"  5.  In  another  series  of  cases  these  foci  extend  by 
continuity  to  the  submucous  tissue — in  the  pars  anterior, 
to  the  periurethral  and  cavernous  spongy  tissue ;  in  the 
pars  posterior,  to  the  prostate. 

"  6.  This  results  in  complicating  focal  processes — 
chronic  periurethritis  in  the  pars  anterior,  prostatitis  in 
the  pars  posterior. 

"  Hence  arises  the  following  classification  of  chronic 
urethritis : 

"  I.  Chronic  anterior  urethritis  :  (a)  Superficial  anterior 
chronic  urethritis ;  (b)  deep  anterior  chronic  urethritis 
(that   is,  plus   chronic  periurethritis). 

"  II.  Chronic  posterior  urethritis :  {a)  Superficial  chronic 
posterior  urethritis ;  (b)  deep  chronic  posterior  urethritis 
(that  is,  plus  chronic  prostatitis). 

"  As  a  matter  of  course,  mixed  forms  are  frequent — 
that  is,  various  foci  in  the  pars  anterior  and  posterior. 


408      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

"  The  relation  of  gonococci  to  chronic  urethritis  is 
extremely  obscure.  .  .  .  Their  virulence  is  weakened 
by  long  proliferation  upon  the  same  soil  for  many  gen- 
erations. As  proof  may  be  cited  the  fact  that  chronic 
blennorrhcea  is  often  conveyed  as  chronic,  much  more 
rarely  as  acute,  blennorrhcea.  The  fact  that  each  suc- 
ceeding relapse  is  milder  and  shorter  also  indicates  that 
the  irritation  of  the  papillary  bod)'  by  the  gonococci 
gradually  diminishes.  The  first  relapses  will  always 
terminate  by  the  removal  of  the  gonococci  to  the  sur- 
face, but  the  virulence  may  finally  be  diminished  to  such 
an  extent  that  the  acute  purulent  symptoms  on  renewed 
invasion  of  the  papillary  body  no  longer  suffice  to  carry 
the  gonococci  to  the  surface.  They  will  then  remain  in 
the  papillary  body,  perhaps  also  in  the  follicles,  and  by 
their  constant  slight  irritation  give  rise  to  the  chronic 
proliferating  processes  in  the  mucous  membrane.  The 
conveyance  of  these  enfeebled  gonococci  would  explain 
the  ab  initio  chronic  infection  in  women  ;  and  their  pro- 
liferation in  the  deep  layers  enables  us  to  understand  the 
fact  that  gonococci  may  or  may  not  be  found  in  the 
secretion,  the  clap-shreds.  But  the  chronic  changes 
induced  by  the  gonococci  may  develop  further  after  the 
cocci  have  perished  from  any  cause.  This  explains  the 
fact  that  in  certain  chronic  blennorrhceas  we  find  the 
secretion  and  clap-shreds,  but  no  gonococci." 

Diagnosis. — The  symptoms  of  chronic  urethritis  are 
usually  so  evident  that  a  diagnosis  of  urethritis  is  readily 
made.  The  difficulty  lies  in  determining  the  seat  and 
nature  of  the  pathological  process.  The  diagnosis  be- 
tween an  exacerbation  of  a  chronic  urethritis  and  a  re- 
cent mild  infection  is  not  difficult  when  it  is  remembered 
that  the  former  appears  in  a  few  hours  after  exposure, 
without  any  period  of  incubation,  is  generally  attended 
by  no  symptoms  other  than  a  trifling  discharge,  subsides 
readily  under  mild  treatment,  and  has  been  preceded  by 
other  similar  relapses  of  more  or  less  recent  date. 

Chronic  prostatitis   may  exist   independently  of  ure- 


CHRONIC   URETHRITIS.  409 

thritis,  and  may  present  symptoms  identical  with  those 
of  the  same  disorder  when  it  complicates  posterior  ure- 
thritis. The  diagnosis  will  depend  upon  the  history  and 
the  absence  of  other  evidences  of  urethral  disease.  Some 
observers  believe  that  gonorrhoea  is  followed  usually  by 
chronic  prostatitis. 

The  adhesion  of  the  lips  of  the  meatus  or  the  appear- 
ance of  an  occasional  drop  of  mucus  does  not  necessarily 
indicate  urethritis.  These  symptoms  may  appear  as  a 
result  of  hypersecretion  of  mucus  by  a  congested  ure- 
thra. This  condition  is  found  in  patients  who  are  irritat- 
ing the  mucous  membrane  of  the  urethra  with  needless 
injections  or  instrumentation  or  merely  by  frequent 
squeezing  of  the  urethra  and  opening  of  the  lips  of  the 
meatus  to  find  the  drop  of  mucus.  It  is  also  found  in 
persons  who  commit  sexual  excesses,  natural  or  un- 
natural, or  who  indulge  in  ungratified  sexual  excitement. 
Under  these  circumstances  the  congestion  and  hyper- 
secretion of  mucus  which  always  attend  an  erection  be- 
come more  or  less  persistent.  The  microscope  shows 
such  a  discharge  to  be  composed  of  mucus  and  epithelial 
elements  without  pus  cells  or  gonococci. 

The  Infectiousness  of  Chronic  Gonorrhcea. — The  discov- 
ery of  characteristic  gonococci  in  the  secretion  or  shreds 
from  the  urethra  at  once  determines  the  case  to  be  one 
of  chronic  gonorrhcea  (Fig.  19).  But  in  the  majority 
of  cases  of  chronic  urethritis  demonstration  of  the  gono- 
cocci is  not  easy,  since  they  are  usually  present  in  small 
numbers  and  associated  with  other  micro-organisms.  In 
a  given  case  drops  of  pus  and  shreds  may  be  examined 
for  a  number  of  days  without  discovering  the  gonococci, 
which  a  few  days  later  may  be  found  in  considerable 
numbers.  Negative  findings  are  not  conclusive,  and  so 
long  as  the  secretion  contains  pus,  the  presence  of  gono- 
cocci should  be  suspected  and  sought  for.  In  exacerba- 
tions of  chronic  urethritis  the  gonococci  increase  in 
numbers  and  can  more  readily  be  demonstrated;  hence 
it  is  justifiable,  when  repeated  examinations  give  nega- 


4IO      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

tive  results,  to  cause  an  artificial  inflammation  of  the 
urethra  for  the  purposes  of  diagnosis.  In  anterior  ure- 
thritis this  object  can  be  accomplished  by  injecting  the 
pars  anterior  a  few  times  with  a  solution  of  bichloride  in 
strength  of  I  :  20,000  or  1  :  10,000;  or  of  nitrate  of  silver, 
1  :  1000  to  1  :  500.  In  posterior  urethritis  a  few  drops 
of  a  1  per  cent,  solution  of  nitrate  of  silver  may  be 
placed  in  the  deep  urethra  with  a  Keyes  syringe  or  a 
solution  containing  1  to  1000  of  this  agent  may  be  used 
as  a  deep  irrigation.  Usually  the  increased  (purulent) 
secretion  which  results  will  show  gonococci  if  these  be 
present.  There  are  cases  of  urethritis  in  which  artificial 
exacerbation  of  the  disease  and  repeated  examinations 
of  the  secretion  fail  to  demonstrate  the  gonococci.  The 
secretion  in  such  cases  is  rarely  anything  more  than 
mucus  resulting  from  a  catarrhal  process  in  an  over- 
stimulated  mucous  membrane,  or  arising  from  some 
localized  area  of  congestion. 

It  is  evident  that  with  a  chronic  urethritis  in  the  secre- 
tion of  which  gonococci  are  present  but  occasionally,  a 
man  may  indulge  in  sexual  intercourse  repeatedly  with- 
out infecting  his  partner,  though  he  has  no  means  of 
knowing  at  what  time  his  discharge  may  become  infec- 
tious. It  is  not  safe,  therefore,  to  allow  a  man  with 
chronic  urethritis  to  marry,  or,  if  married,  to  resume 
marital  intercourse,  until  during  several  weeks  of  fre- 
quent examinations  the  discharge  shows  no  gonococci 
and  the  clinical  symptoms  point  strongly  to  the  presence 
of  nothing  more  than  a  catarrhal  discharge. 

On  this  subject  Finger  says :  "  I  permit  a  patient  who 
is  suffering  from  chronic  blennorrhcea — that  is,  the  morn- 
ing drop  or  clap-shreds — to  have  marital  intercourse  only 
after  I  have  convinced  myself,  by  a  two  to  four  weeks' 
daily  examination  of  the  secretion  or  clap-shreds,  that 
these  contain  only  epithelium,  and  no  pus-cells,  and  when, 
after  irrigation  of  the  urethra  with  a  solution  of  silver 
nitrate  or  corrosive  sublimate,  and  consequent  suppura- 
tion, the   secretion  is  entirely  free  from  gonococci,  and 


CHRONIC   URETHRITIS.  4II 

there  is  no  further  indication  for  the  continuance  of 
treatment.  The  conditions  which  I  require  are,  accord- 
ingly, the  absence  of  gonococci,  pus-corpuscles,  and  peri- 
urethral complications." 

Noeggerath  believes  that  if  a  man  once  have  a 
urethral  discharge  containing  gonococci,  he  never 
fully  recovers,  and  that  nine-tenths  of  the  women  mar- 
ried to  men  who  have  had  gonorrhoea  eventually 
develop  pelvic  inflammation  due  to  infection  by  the 
gonococci.  Such  inflammations  are  usually  subacute 
in  their  origin,  and  often  date  from  the  birth  of  the  first 
child.  On  the  other  hand,  many  cases  of  chronic  gonor- 
rhoea have  been  investigated  by  competent  observers  in 
which  no  gonococci  could  be  demonstrated  either  with 
the  microscope  or  by  the  aid  of  cultures.  It  is  probable 
that  a  chronic  gonorrhoea  in  which  there  is  no  reinfection 
from  time  to  time,  and  no  recurrences  of  an  acute  type, 
will  gradually  lose  its  infectiousness.  If  repeated  ex- 
aminations during  a  period  of  two  or  three  weeks  fail  to 
find  gonococci,  shreds,  or  more  than  a  few  pus  cells,  an 
acute  purulent  urethritis  should  be  induced  by  the 
means  described  above,  and  the  discharge  carefully  and 
repeatedly  examined.  If  no  micro-organisms  are  found, 
the  case  is  evidently  no  longer  infectious  and  the  patient 
may  be  permitted  to  marry.  In  case  diplococci  are 
found  in  the  discharge,  culture-tests  should  be  employed 
before  deciding  the  question.  Indeed,  cultures  should 
be  used  in  all  cases  when  possible. 

Localization  of  Lesions. — In  all  cases  of  chronic 
urethritis  it  is  necessary  to  determine  the  extent,  loca- 
tion, and  nature  of  the  pathological  process.  In  the 
majority  of  cases  this  is  limited  to  small  circumscribed 
areas,  but  in  more  recent  cases,  and  in  those  giving  a 
history  of  frequent  relapses  or  continued  local  treatment, 
the  entire  mucous  membrane  may  be  the  seat  of  a  sub- 
acute inflammation,  or  at  least  of  a  chronic  congestion. 
When  a  large  portion  of  the  urethra  is  thus  involved, 
there  will  be  a  more  abundant  secretion,  and  the  urine 


412       SYPHILIS  AND    THE   VENEREAL   DISEASES. 

containing  the  washings  of  the  urethra  will  be  cloudy 
from  the  presence  of  pus  or  of  mucus.  Examination 
with  instruments  for  the  local  lesion  should  be  postponed 
until  the  more  general  disturbance  has  been  removed  by 
proper  treatment. 

The  first  step  in  locating  the  seat  of  a  chronic  urethri- 
tis is  to  determine  if  it  be  in  the  anterior  or  the  posterior 
urethra. 

1.  History  and  Symptoms. — If  there  be  a  history  of 
epididymitis,  prostatitis,  cystitis,  vesiculitis,  tenesmus,  or 
other  symptoms  pointing  to  a  former  acute  posterior 
urethritis,  it  is  quite  probable  that  in  the  posterior 
urethra  will  be  found  the  lesion  responsible  for  the 
chronic  disorder.  Subjective  sensations  are  usually 
insignificant  or  wanting  in  chronic  urethritis  of  the  pars 
anterior,  but  if  the  pars  posterior  be  involved  there  are 
usually  ill-defined  sensations  and  pains  in  the  perineal 
region,  and  sensitiveness  of  this  portion  of  the  urethra 
on  pressure  upon  the  perineum  or  through  the  rectum ; 
there  may  be  frequency  of  urination,  tenesmus,  and 
other  symptoms  pointing  to  the  presence  of  chronic 
prostatitis. 

2.  The  Discharge. — If  the  discharge  arises  from  some 
portion  of  the  pendulous  urethra,  it  will  gravitate  to 
the  meatus,  and  appear  there  occasionally  as  a  yellow- 
ish, milky,  or  transparent  drop,  or  it  may  lightly  glue 
together  the  lips  of  the  meatus.  When  the  process  is 
situated  in  the  bulb,  the  discharge,  if  small  in  amount, 
may  remain  in  situ  until  washed  out  by  the  urine.  Dis- 
charges arising  from  the  pars  posterior  will  not  appear 
at  the  meatus  during  the  intervals  of  urination,  but  will 
remain  in  the  prostatic  portion  or  will  pass  backward 
into  the  bladder. 

3.  Examination  of  Urine. — When  the  pathological 
process  has  become  limited  to  circumscribed  areas, 
neither  pus  nor  mucus  will  accumulate  sufficiently  to 
appear  as  a  discharge  or  to  render  the  urine  cloudy, 
but  the  urine  may  contain  flakes  or   shreds  composed 


CHRONIC   URETHRITIS.  413 

of  mucus,  pus,  and  epithelium.  The  shreds  may  be 
transparent,  delicate,  narrow  threads,  often  very  long 
and  branched.  These  threads  are  composed  chiefly 
of  mucus  and  epithelium,  show  a  tendency  to  float  in 
the  urine,  and  in  general  indicate  superficial  and  milder 
lesions  of  the  urethra.  Other  shreds  are  shorter,  firmer, 
and  opaque,  and  contain  a  greater  number  of  pus-cells. 
Such  shreds  sink  rapidly  to  the  bottom  and  indicate 
a  more  serious  condition.  A  third  type  of  shreds  is 
sometimes  found  in  the  form  of  short,  firm,  comma- 
like plugs  or  flocculi.  These  particles  come  from 
the  excretory  ducts  of  the  various  glands  and  follicles 
of  the  urethra  that  may  be  involved  in  the  process.  The 
character  of  the  shreds  gives  some  clue  to  the  nature 
and  intensity  of  the  urethral  disorder,  but  does  not 
give  reliable  information  regarding  the  location  of  the 
lesion.  If,  however,  the  shreds  contain  spermatozoa,  or 
if  they  are  of  the  comma-like  variety  and  are  present  in 
the  second  portion  of  the  urine,  they  come  from  the 
prostatic  urethra.  For  microscopical  examination  the 
shreds  and  other  sediment  should  be  obtained  with  a 
centrifuge  and  examined  while  fresh. 

The  urine  should  be  examined  by  the  two-glass 
method,  though  this  test  is  of  less  value  than  in  acute 
urethritis,  since  the  small  amount  of  pus  formed  in  the 
posterior  urethra  will  be  removed  in  the  act  of  urinating 
before  sufficient  has  accumulated  to  pass  back  into  the 
bladder,  and  during  the  day,  while  the  urine  is  passed 
at  frequent  intervals,  that  in  the  second  glass  will  be 
clear  and  free  from  shreds.  But  if  the  urine  be  retained 
several  hours  until  the  prostatic  urethra  is  well  dilated, 
forming  practically  a  part  of  the  bladder,  the  pus  and 
the  shreds  will  mix  with  the  urine  in  the  bladder  and 
appear  in  the  second  glass.  Hence  it  is  important  that 
the  patient  bring  his  morning  urine  passed  in  two  bottles, 
and  that  he  again  urinate  in  two  glasses  at  the  time  of 
his  visit  to  the  physician.  Another  condition  may  be 
present,  even  when  the  urine  in  the  bladder  is  clear,  to 


414      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

cause  cloudiness  and  shreds  in  the  second  glass :  if  the 
prostatic  glands  are  inflamed,  pus  and  comma-like  plugs 
may  be  pressed  out  by  the  contraction  of  the  muscle  at 
the  close  of  urination,  appearing  with,  or  just  after,  the 
last  drops  of  urine.  This  last  portion  may  be  collected 
in  a  third  glass.  For  accuracy  in  diagnosis  this  test 
with  the  glasses  should  be  preceded  by  a  thorough 
irrigation  of  the  anterior  urethra,  care  being  taken  not 
to  interfere  with  the  return  flow  lest  the  deep  urethra 
be  cleansed  unintentionally.     In  the  first  glass  will  be 


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Fig.  ig. — Pus  taken  from  an  old  case  of  gleet  with  a  recent  reinfection,  showing  old 
threads  and  pus-cells  with  gonococci  (Wood). 

seen  the  washings  of  the  deep  urethra ;  in  the  second, 
the  urine  of  the  bladder;  and  in  the  third,  the  secre- 
tion squeezed  out  of  the  prostatic  follicles.  If  the  symp- 
toms point  to  the  involvement  of  the  prostate,  it  is  ad- 
visable to  have  the  patient  retain  the  last  ounce  or  two 
of  urine  in  the  bladder  until  after  the  physician's  finger 
in  the  rectum  has  gently  pressed  out  the  contents  of 
some  of  the  follicles.  The  amount  of  prostatic  secretion 
in  the  last  glass  may  thus  be  increased  considerably. 
Clear  urine  in  all  three  glasses  means  that  the  disease 


CHRONIC   URETHRITIS.  415 

is  limited  to  the  pars  anterior ;  clear  urine  in  the  second 
glass,  with  pus  or  shreds  in  the  first,  or  in  first  and 
third,  means  posterior  urethritis  without  cystitis  ;  shreds 
and  pus  in  the  third  glass,  when  the  rest  of  the  urine  is 
clear,  show  the  process  to  be  limited  to  the  prostatic 
follicles.  If  all  the  urine  contains  pus  and  mucus,  in- 
flammation of  the  bladder  or  of  the  kidneys  is  probably 
present.  In  this  case  other  examinations  should  be 
made,  and  especially  of  urine  that  has  been  retained  in 
the  bladder  but  a  short  time ;  for  when  the  latter  is  at 
all  distended,  the  prostatic  urethra  is  also  dilated  and 
pus  from  this  region  passes  back  and  mixes  with  the 
urine  in  the  bladder.  If  the  second  glass  at  any  time 
shows  clear  urine,  cystitis  may  be  excluded. 

A  simpler  method  of  locating  the  origin  of  shreds 
in  the  urine  is  found  in  completely  filling  the  ante- 
rior urethra  by  means  of  a  gonorrhceal  syringe  with 
a  solution  of  methylene-blue  or  other  stain.  This 
solution  is  left  in  the  urethra  for  one  or  two  minutes  and 
is  then  allowed  to  escape.  The  patient  should  now 
urinate  in  two  glasses.  The  first  portion  of  urine  may 
thus  contain  shreds  from  all  parts  of  the  urethra,  but 
those  from  the  pars  anterior  will  be  blue,  while  those 
from  the  pars  posterior  will  be   unstained. 

4.  Examination  with  Sounds  and  Bougies. — In  a  large 
proportion  of  cases  of  chronic  urethritis  stricture  in 
some  form  is  present,  and  in  an  instrumental  examina- 
tion of  the  urethra  is  the  first  thing  to  be  searched  for. 
A  detailed  description  of  instruments  and  of  the  tech- 
nique of  urethral  instrumentation  is  given  in  the  dis- 
cussion of  Stricture,  and  is  not  repeated  here. 

When  no  stricture  can  be  found,  other  forms  of  local 
lesions  that  may  be  present  can  often  be  located  accu- 
rately by  means  of  the  steel  sound  or  the  rubber  bougie. 
It  is  always  well  to  begin  with  a  blunt  steel  sound  of 
the  largest  size  that  will  easily  pass  the  meatus.  This 
larger  sound,  warmed  and  oiled,  causes  less  pain  than 
smaller  ones,  or  than  bulbous  bougies  or  urethrometers 


41 6      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

and  will  often  answer  every  purpose.  The  sensa- 
tions of  the  patient  on  the  first  passage  of  any  sound 
should  not  be  relied  upon  for  the  location  of  diseased 
areas,  as  the  entire  mucous  membrane  is  often  so  sensi- 
tive that  the  patient,  usually  nervous  and  apprehensive 
in  this  his  first  experience  with  a  sound,  cannot  tell 
definitely  at  what  points  the  passage  of  the  instrument 
causes  him  the  most  pain.  In  most  cases  all  decided 
pains  disappear  when  the  sound  ceases  to  move,  and  it 
should  be  held  quietly  in  the  urethra  for  from  one  to 
five  minutes  until  the  sensitiveness  of  the  membrane  is 
lessened  and  the  fears  of  the  patient  are  overcome,  when 
it  should  be  withdrawn  gently  and  at  once  reintroduced, 
gently  and  slowly.  Its  second  introduction  will  cause 
the  patient  comparatively  little  uneasiness  except  when 
the  tip  of  the  instrument  comes  in  contact  with  areas  of 
disease  (inflamed  follicles,  granular  patches,  or  superficial 
ulcers).  At  these  points  he  will  probably  experience  the 
sensation  of  burning  or  sharp,  sticking  pains.  With  the 
sound  held  in  the  urethra  with  one  hand,  the  fingers  of 
the  other  hand  may  explore  the  pendulous  portion  and 
accurately  locate  areas  of  thickening  and  sensitive 
points. 

In  disease  of  the  pars  posterior  or  of  the  prostate 
gland  passage  of  the  sound  through  the  deep  urethra 
may  be  accompanied  by  great  pain  and  violent  tenes- 
mus. If  relief  does  not  quickly  follow  when  the  sound 
is  held  still,  it  should  at  once  be  withdrawn  from  this 
part  of  the  urethra.  In  neurasthenics  and  in  cases  of 
urethral  hyperaesthesia  the  first  attempts  to  sound  the 
urethra  may  be  very  painful,  the  muscular  fibres  of  the 
urethra  contracting  about  the  instrument,  forming  spas- 
modic strictures  which  interfere  with  the  passage  of  the 
sound.  In  these  cases  patience,  gentleness,  and  repeated 
examinations  are  required  before  the  limited  areas  of 
disease  can  be  located  or  before  the  sound  can  be  passed 
fully  into  the  bladder. 

In  less  sensitive  urethras,  when  the  blunt  sound  fails 


CHRONIC   URETHRITIS.  417 

to  accurately  locate  the  urethral  lesions,  the  bulbous 
bougie  or  the  urethrometer  may  be  used.  The  largest 
sized  bulbous  bougie  that  can  readily  be  introduced  is 
oiled  and  passed  to  the  deep  urethra.  It  is  then  slowly 
withdrawn,  and  as  the  shoulders  of  the  bulb  come  in 
contact  with  granulating  and  other  sensitive  areas  the 
patient  experiences  sharp  pains  or  sticking  sensations. 
If  on  repeated  examinations  the  patient  complains  of 
pain  at  the  same  points,  the  lesions   are  thus  located. 

5.  Endoscopic  Examination. — Some  few  conditions  of 
the  urethra,  such  as  tumors,  polypi,  granular  patches, 
and  ulcerations,  are  best  recognized  and  treated  by  means 
of  the  endoscope.  This  instrument  has  a  somewhat  re- 
stricted field  of  usefulness,  since  its  successful  employ- 
ment calls  for  much  experience  and  practice  on  the  part 
of  the  operator,  and  the  introduction  of  the  straight  en- 
doscopic tubes  is  attended  by  much  more  pain  and  irrita- 
tion of  the  urethra  than  is  caused  by  the  passage  of  sounds. 
The  endoscope  should  never  be  used  during  acute,  or  even 
subacute,  stages  of  urethritis,  for  fear  of  aggravating  the 
existing  inflammation.  It  is  of  service  chiefly  in  those 
cases  of  chronic  urethritis  in  which  other  methods  of 
diagnosis  and  treatment  have  proved  insufficient.  It  is 
always  well  to  postpone  the  use  of  the  endoscope  in  any 
case  until  the  sensitiveness  of  the  urethra  has  been  tested 
and  lessened  by  the  use  of  sounds. 

(a)  Description  of  Instruments. — Since  Desormeaux 
first  made  practical  use  of  the  endoscope  in  1853,  numer- 
ous modifications  of  his  instrument  have  appeared,  as 
well  as  some  entirely  new  devices  for  exposing  to  view 
the  mucous  membrane  of  the  urethra.  In  the  method 
recommended  by  Gruenfeld,  and  the  one  which  has  most 
frequently  been  employed,  the  endoscopic  tubes  are  sep- 
arate from  the  illuminating  apparatus.  Gruenfeld's  orig- 
inal tubes  have  been  modified  by  Steuer,  and  again  by 
Klotz  (Fig.  20).  Either  of  the  two  modifications  is  prob- 
ably better  than  the  original  tube,  since  the  flat  disk  pre- 
vents painful  distention  of  the   meatus   when   the   tube 

27 


418      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

is  forced  back  upon  the  glans,  thus  shortening-  the  penis 
and  allowing  inspection  of  the  entire  urethra  by  a  tube 


Fig.  20. — Klotz's  endoscope  (Tiemann). 


much  shorter  than  the  urethra  itself.  Tubes  should  be 
of  metal  or  of  hard  rubber.  In  many  respects  the  Klotz 
tube  of  coin-silver  is  best,  since  it  is  light,  easily  cleaned, 
and  has  thin  walls,  which  allow  a  wider  bore  for  the  same 
size  of  tube. 

The  tubes  needed  will  vary  in  diameter  from  16  to  34, 
French  scale,  and  in  length  from  three  to  five  and  a 
half  inches.  As  a  rule,  a  tube  of  the  largest  diameter 
that  will  pass  the  meatus  should  be  used,  in  order  to 
give  the  best  illumination  and  the  largest  view  possible. 
In  the  pendulous  urethra  specula  (Figs.  21  and  22) 
may  be  used  instead  of  tubes.     They  have  an  advantage 


Fig.  21. — Urethral  speculum  (Tiemann). 


Fig.  22.— Urethral  speculum  (Tiemann). 


over  the  latter  in  displaying  larger  areas  at  a  time,  but 
the  pressure  produced  by  the  sides  of  the  instrument 
causes  more  or  less  anaemia  of  the  mucous  membrane, 
and  consequently  modifies  its  appearance. 


CHRONIC   URETHRITIS. 


419 


Illumination  is  obtained  by  means  of  an  ordinary  mir- 
ror such  as  is  used  in  examinations  of  the  larynx.  This 
may  be  fastened  to  a  handle  or,  better,  to  a  head-band. 
The  source  of  light,  in  order  of  desirability,  may  be 
direct  sunlight,  bright  diffused  daylight,  electric  or  gas 
light,  or  a  kerosene  lamp.  If  an  artificial  light  is  used, 
it  should  be  mounted  on  a  freely  movable  and  adjusta- 
ble bracket.  The  addition  of  a  condenser  will  improve 
the  illumination.  An  excellent  apparatus  is  that  devised 
by  Dr.  F.  Tilden  Brown  (Fig.  23). 


Fig.  23. — Brown's  method  of  illuminating  the  urethra. 


In  another  type  of  endoscope  the  tube  is  directly  con- 
nected with  an  electric  illuminating  apparatus.  The 
Leiter  electro-endoscope,  used  and  recommended  by 
Finger,  has  been  modified  by  several  operators  in  America. 
The  Otis  electro-urethroscope  (Fig.  24)  is  probably  as 
serviceable  as  any  endoscope  of  this  type.  It  has  the 
great  advantage  of  being  but  one-sixth  as  heavy  as 
Leiter's  instrument. 

By  far  the  most  satisfactory  endoscope,  and  the 
simplest  to  use,  is  one  recently  produced  by  the  Electro- 


420      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

surgical  Instrument  Company  of  Rochester,  N.  Y.  (Fig# 
25).     The  light  is  a  minute  incandescent  lamp,  which, 


Fig.  24. — W.  K.  Otis's  "perfected"  urethroscope  (Tiemann). 


with  its  carrier,  is  placed  in  a  small  tube  along  the  under 
side  of  the  endoscopic  tube  proper.  A  direct  light  is 
thus  thrown  upon  the  tissue  to  be  examined,  and  at  the 
same  time  the  lamp  is  not  in  the  way  of  applications 
to  the  membrane.  So  little  heat  is  generated  that  the 
tube  may  remain  in  place  ten  or  fifteen  minutes  without 
discomfort  to  the  patient.  The  lamp  is  connected  by 
cords  with  a  small  dry-cell  battery.     The  entire  appa- 


Fig.  25. — Koch's  tube,  for  use  with  Valentine's  urethroscope. 

ratus  is  light,  simple,  easily  managed,  and  gives  an  ex- 
cellent illumination  of  the  urethra. 

(d)  Method  of  Examination. — For  endoscopic  examina- 
tion of  the  urethra  the  patient  should  be  placed  on  a  table 
or  an  operating-chair  that  will  bring  the  genitals  on  a 
level  with  the  eyes  of  the  operator,  who  sits  in  front.  If 
a  separate  reflector  is  used,  the  rays  of  light  should  come 
from  a  little  to  one  side  of  the  patient,  and  should  so  strike 
the  reflector  that  the  best  possible  illumination  of  the  ure- 


CHRONIC   URETHRITIS.  421 

thra  may  be  obtained.  For  examination  of  the  anterior 
urethra  with  the  last  described  endoscope,  the  position 
of  the  patient  is  not  important.  Cotton,  tampons,  and 
tampon-carriers  (in  the  form  of  long  wires  or  thin  strips 
of  wood,  that  can  be  thrown  away  after  using  once) 
should  be  within  easy  reach  of  the  operator.  With  the 
penis  at  an  angle  of  from  900  to  1 300  with  the  abdomen, 
the  warmed  and  well-oiled  tube,  with  its  proper  obturator, 
is  directed  along  the  upper  wall  of  the  urethra  to  the 
bulb,  where  it  meets  with  resistance.  The  tube  is  now 
in  position  to  begin  examination  of  the  pars  anterior. 

The  endoscope  is  of  but  little  value  in  the  poste- 
rior urethra,  and  its  use  here  should  be  attempted 
by  none  but  an  expert.  If,  however,  the  pars 
posterior  is  to  be  examined,  the  proximal  (ocular) 
end  of  the  instrument  is  depressed  and  gently  pushed 
on  until  the  visceral  end  enters  the  neck  of  the 
bladder,  when  partial  removal  of  the  obturator  will  allow 
some  escape  of  urine  if  the  bladder  be  moderately  full, 
and  the  position  of  the  tube  is  thus  easily  demonstrated. 
The  tube  is  then  withdrawn  slightly,  to  the  prostatic  ure- 
thra, and  the  examination  is  begun.  The  passage  of  the 
straight  instrument  through  this  portion  of  the  urethra 
is  painful,  and  is  also  difficult  of  execution — sometimes 
impossible.  In  some  men  it  will  be  necessary  to  depress 
the  ocular  end  of  the  tube  but  to  a  horizontal  line,  while 
in  others  it  must  be  carried  much  lower  and  consider- 
able force  must  be  employed.  It  is  not  wise  to  attempt 
an  endoscopic  examination  of  the  pars  posterior  during 
the  first  visit  of  a  patient  or  before  the  pars  anterior  has 
been  inspected  carefully. 

In  making  an  endoscopic  examination  the  tube  should 
be  inserted  to  the  deepest  part  to  be  examined,  and  then 
slowly  withdrawn,  the  operator  cleaning  and  inspecting 
each  portion  of  the  mucous  membrane  as  it  comes  in 
view  at  the  distal  end  of  the  tube. 

(c)  Appearance  of  the  Normal  Urethra. — To  use  the 
endoscope  successfully  the    operator    must  be  familiar 


422      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

with  the  appearances  of  the  different  portions  of  the 
normal  urethra.  Such  knowledge  can  come  only 
through  much  experience,  and  cannot  be  gained  solely 
from  written  descriptions,  or  even  from  plates.  In  the 
normal  condition  the  urethra  is  not  a  tube  with  a  definite 
calibre,  but  is  a  closed  valve,  the  walls  being  in  contact 
and  lying  in  longitudinal  folds.  The  introduction  of 
the  endoscopic  tube  separates  the  walls  and  smooths 
out  the  folds.  A  short  distance  from  the  end  of  the 
tube,  however,  the  walls  again  come  together  in  the 
form  of  a  funnel,  the  folds  radiating  to  a  central  point 
or  a  short  line  which  has  much  the  appearance  of  a 
sphincter  and  is  called  the  "  central  figure."  As  the 
tube  is  slowly  withdrawn  the  funnel  follows,  but  if  the 
tube  be  pushed  backward,  or  if  the  one  employed  be 
too  small  for  a  given  urethra,  the  folds  of  mucous  mem- 
brane will  fall  together  directly  at  the  end  of  the  tube, 
or  will  even  project  into  it. 

In  the  posterior  portion  of  the  prostatic  urethra  the 
tunnel  is  short  and  the  surface  is  smooth  or  but  slightly 
ridged  and  of  a  dark-red  color.  As  the  tube  is  with- 
drawn the  membrane  becomes  paler,  and  a  flat  or 
rounded  protuberance  appears  at  the  lower  edge  of  the 
tube.  This  protuberance  gradually  increases  in  size 
until  it  occupies  about  three-fourths  of  the  field  of 
vision,  and  the  funnel  above  appears  in  the  form  of 
a  crescent.  The  protuberance  is  formed  by  the  collicu- 
lus  seminalis,  on  the  summit  of  which,  in  favorable  cases, 
may  be  seen  the  opening  of  the  utricle.  On  further 
withdrawing  the  tube  the  colliculus  gradually  disappears, 
but  its  prolongation  may  remain  in  the  field  until  the 
bulb  is  reached.  On  either  side  of  the  colliculus  is  a 
deep  furrow.  The  tube  may  pass  through  one  of  these 
furrows,  so  that  the  colliculus  is  not  seen  at  all  or 
appears  at  one  side.  The  picture  obtained  in  the  pros- 
tatic urethra  is  a  complicated  one,  and  differs  greatly  in 
different  individuals. 

In  the  membranous  urethra  the  mucous  membrane  is 


CHRONIC   URETHRITIS.  423 

paler  in  color  than  in  the  prostatic  portion,  and  the  fun- 
nel is  short  and  regular,  the  "  central  figure "  being  a 
point.  In  passing  to  the  bulbous  portion  the  picture 
may  change  gradually  and  but  slightly,  though  more  fre- 
quently the  funnel  becomes  shorter  and  the  folds  much 
larger.  The  latter  may  push  into  the  tube  in  the  shape 
of  two  external  ridges  which  touch  in  the  centre  and 
give  the  central  figure  the  form  of  a  vertical  line  or 
fissure.  The  contractions  of  the  bulbo-cavernosi  and 
ischio-cavernosi  muscles  may  render  it  difficult  to  keep 
the  tube  in  the  bulb.  This  object  can  be  accomplished 
by  the  use  of  force  or  by  elevating  the  ocular  end  of  the 
instrument  as  in  the  removal  of  a  sound. 

In  the  pendulous  urethra  the  funnel  is  again  regular, 
the  folds  uniting  in  a  central  figure  in  the  form  of  a  hori- 
zontal slit.  The  color  of  the  membrane  is  pink  or  pale 
red.  Along  the  upper  wall  may  be  seen  small,  pin-point- 
sized  depressions.  These  are  the  lacunae  Morgagni.  In 
the  glans  the  central  figure  is  triangular,  except  in  the 
fossa  navicularis,  where  it  is  vertical.  The  membrane 
loses  some  of  its  red  color  and  adds  a  bluish  tint.  At 
the  meatus  it  is  of  almost  a  slate  color. 

(d)  Appearance  of  the  Urethra  in  Disease. — The 
shape  and  size  of  the  funnel  will  be  modified  variously, 
depending  upon  the  nature  and  extent  of  the  infiltration 
and  thickening  present  in  the  urethral  walls.  If  the 
mucous  membrane  is  cedematous,  the  natural  folds  will 
be  increased  in  size  and  will  come  together  nearer  the 
end  of  the  tube,  forming  a  short,  narrow  funnel ;  or  if 
this  swelling  be  soft  and  considerable,  the  membrane 
will  bulge  into  the  end  of  the  tube.  In  this  condition 
the  folds  and  the  funnel  re-form  rapidly  after  moving  the 
tube.  If  there  be  firmer  and  deeper  infiltration  of  the 
tissues  than  in  the  condition  just  described,  the  walls  of 
the  urethra  will  not  come  together  so  readily,  the  funnel  is 
longer  and  larger  and  more  rigid,  and  the  changes  occur 
slowly.  In  either  form  of  infiltration  and  swelling,  if  the 
process  be   unilateral,  unequal,  or  irregular,  the  funnel 


424      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

will  be  unsymmetrical,  the  central  figure  will  be  variously 
distorted,  and  irregular  folds  may  bulge  into  the  tube. 

While  pathological  changes  in  the  deeper  tissues  can 
thus  be  recognized,  the  endoscope  is  chiefly  valuable 
in  demonstrating  and  treating  lesions  on  the  surface  of 
the  mucous  membrane.  The  color  of  small  or  even 
large  areas  may  be  changed  from  the  normal  pink  to  a 
bright  red  or  to  some  of  the  darker,  duller  shades  of 
bluish  and  brownish  red  or  purple;  or,  on  the  contrary, 
it  may  be  almost  white.  The  normal  dull  lustre  may  be 
lost,  and  the  surface  may  appear  smooth  and  shining  or 
even  glistening,  or  rough,  dull,  and  cloudy.  Losses  of 
epithelium  give  the  surface  a  finely  stippled  appearance. 
Areas  of  granulation  are  of  frequent  occurrence  and  are 
readily  recognized.  Morgagni's  lacunae  are  often  in- 
volved in  chronic  urethritis,  and  appear  as  circumscribed 
reddened  and  swollen  areas,  or  as  sharply  defined  pin- 
head-sized  or  larger  pits  or  depressions.  Small  areas  of 
superficial  ulceration  may  be  found.  These  areas  are 
very  sensitive,  may  appear  depressed,  and  lack  the 
smoothness  and  lustre  of  the  normal  membrane.  Occa- 
sionally tumors  may  be  present  in  the  urethra  and  be 
the  cause  of  slight  persistent  discharge  or  disturbances 
in  urination.  These  tumors  are  recognized  by  the  en- 
doscope in  the  form  of  smooth  polypi  or  more  frequently 
as  small  warts  or  papillomatous  growths.  The  latter  are 
usually  situated  near  the  meatus. 

The  above-described  pathological  changes  are  found 
chiefly  in  the  bulbous  and  pendulous  portions  of  the 
urethra.  In  the  pars  posterior  they  are  found  less  fre- 
quently and  are  not  so  well  understood.  Endoscopic 
examination  of  this  region  is  not  often  called  for,  though 
it  is  occasionally  of  great  service  in  both  diagnosis  and 
treatment.  The  straight  tube  does  not  readily  enter  the 
prostatic  urethra  without  the  application  of  some  force, 
and  the  resulting  hemorrhage  not  infrequently  is  suffi- 
cient to  prevent  an  accurate  inspection  of  these  parts. 

Treatment  of  Chronic  Urethritis. — It   is   difficult  to 


CHRONIC   URETHRITIS.  425 

lay  down  definite  rules  for  the  management  of  chronic 
urethritis,  since  so  much  depends  on  the  individual,  his 
habits  and  surroundings,  and  on  the  duration,  character, 
and  previous  treatment  of  his  disease.  Frequently  the 
condition  of  the  patient,  more  than  that  of  his  urethra, 
should  be  considered.  In  cachectic  individuals  local 
treatment  of  the  urethritis  may  accomplish  little  as  com- 
pared with  properly  directed  constitutional  treatment. 
In  cases  of  simple  anaemia,  debility,  or  exhaustion,  rest 
and  proper  tonics  will  often  be  more  effective  in  caus- 
ing the  disappearance  of  a  urethral  discharge  than  will 
any  amount  of  local  treatment.  In  men  who  have  been 
violating  the  laws  of  sexual  and  general  hygiene,  chang- 
ing the  habits  of  living  to  conform  with  these  laws  may 
make  other  treatment  unnecessary,  and  until  such  changes 
are  made  local  treatment  will  do  little,  if  any,  good. 

The  hygiene  of  chronic  urethritis  is  practically  that  of 
the  acute  disease,  except  that  greater  freedom  is  allowed 
the  patient  in  matters  of  diet  and  exercise.  Tobacco, 
alcohol,  and  rich  or  highly  seasoned  foods  should  be  inter- 
dicted ;  sexual  excitement  and  unrest  must  be  avoided. 
For  the  unmarried  man  absolute  continence,  both  mental 
and  physical,  is  the  only  course.  In  married  men  moder- 
ate, unstimulated  sexual  relations  are  permissible,  or  even 
beneficial,  in  cases  of  slight,  persistent  discharges  which 
the  physician  is  satisfied  are  non-infectious.  The  un- 
married man  who  has  been  tormenting  both  mind  and 
body  in  his  ceaseless  efforts  to  remove  the  last  traces 
of  a  catarrhal  discharge  from  the  urethra  and  to  pre- 
pare himself  for  matrimony,  and  whose  morbid  mental 
condition  interferes  with  sexual  hygiene  by  keeping  the 
organs  in  a  state  of  unrest,  finds  that  after  marriage  his 
symptoms  , rapidly  disappear.  Keyes  says:  "A  regular, 
moderate  exercise  of  the  sexual  organs  tends  surely  to 
keep  down  congestion  and  to  allow  that  rest  which  is 
most  important  in  effecting  a  cure."  It  is  needless  to 
add  that  such  exercise  of  the  sexual  organs  cannot  be 
found   outside  of  the   married   state ;   and,   furthermore, 


426      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

the  mental  and  moral  influence  upon  such  a  man  of  his 
marriage  to  a  pure-minded  woman  is  a  large — frequently 
the  most  important — factor  in  effecting  his  recovery.  In 
such  cases  the  physician  will  not,  of  course,  recommend 
marriage  until  he  is  satisfied  that  the  urethral  discharge 
is  non-infectious  and  that  the  man  is  resolutely  endeavor- 
ing to  live  according  to  the  laws  of  sexual  hygiene.  It 
must  not  be  understood  that  marriage  is  here  recom- 
mended as  a  therapeutic  measure.  The  foregoing  re- 
marks apply  to  the  man  who,  having  repented  his  early 
follies,  and  earnently  desiring  to  wed  the  woman  of  his 
choice,  hesitates  through  fear  of  his  physical  unfitness 
for  marriage. 

The  use  in  the  urethra  of  strong  injections,  of  bulbous 
sounds,  of  dilating  instruments,  or  of  the  endoscope 
necessarily  irritates  the  otherwise  healthy  portions  of  the 
mucous  membrane,  causing  temporary  inflammation  of 
these  areas.  Even  mild  injections  and  the  blunt  steel 
sound  are  slightly  irritating  to  the  normal  mucous  mem- 
brane, and  their  use  is  followed  by  some  hypersecretion 
of  mucus.  Hence  the  folly  of  continuing  local  treatment 
indefinitely  in  hope  of  removing  the  last  drop  of  mucus 
which  appears  at  the  meatus,  and  hence  the  impossibility 
of  making  an  accurate  diagnosis  in  a  case  of  urethritis 
that  is  being  treated  locally. 

In  undertaking  the  management  of  a  case  of  chronic 
urethritis  that  has  been  under  more  or  less  constant  local 
treatment,  it  is  always  advisable  to  give  the  urethra  a  rest 
for  several  days  at  least  before  again  beginning  topical  ap- 
plications. This  rest  gives  the  mucous  membrane  a 
chance  to  recover  from  the  irritation  produced  by  local 
interference,  and  allows  the  surgeon  at  the  end  of  this 
time  to  determine  with  greater  accuracy  the  nature  of 
the  organic  lesions  that  may  be  present.  It  also  happens 
that  the  same  local  treatment  which  was  ineffective  when 
pursued  constantly  will,  after  such  a  rest,  be  followed  by 
prompt  and  beneficial  results.  In  cases  in  which  no  or- 
ganic lesions  are  present,  cessation  of  local  treatment  for 


CHRONIC   URETHRITIS.  427 

a  week  or  two  may  result  in  complete  disappearance  of 
the  urethritis.  Such  cases  are  more  numerous  than  the 
majority  of  practitioners  are  willing  to  believe.  Many 
of  the  so-called  "  incurable  "  cases  of  chronic  urethritis, 
which  refuse  to  yield  after  months  or  years  of  treatment, 
need  only  rest  and  hygiene  to  bring  about  their  recovery. 
In  stopping  all  local  treatment  it  may  be  well  at  first  to 
give  small  doses  of  sandalwood  or  of  cubebs.  The  urine 
should  be  kept  unirritating  at  all  times.  The  pernicious 
habit  practised  by  many  patients  of  frequently  squeezing 
and  examining  the  urethra  must  be  abolished. 

For  purposes  of  treatment  all  cases  of  chronic  ure- 
thritis may  roughly  be  divided  into  two  classes.  The  first 
class  includes  those  cases  in  which  a  considerable  por- 
tion or  all  of  the  urethral  mucous  membrane  is  involved 
to  a  greater  or  lesser  degree.  This  condition  is  found 
in  cases  following  a  recent  gonorrhoea,  in  relapses  and 
exacerbations  of  chronic  urethritis,  in  urethras  subjected 
to  constant  or  excessive  local  treatment,  and  in  the  chron- 
ic urethritis  of  men  who  are  cachectic  or  who  are  not 
living  hygienically.  The  amount  of  secretion  in  these 
cases  may  be  considerable,  and  may  vary  from  a  mere 
hypersecretion  of  mucus  to  a  more  or  less  purulent  dis- 
charge resulting  from  a  true  inflammation  of  the  mem- 
brane. If  posterior  urethritis  be  present,  the  second 
portion  of  the  urine  will  be  cloudy.  The  second  class 
includes  those  forms  of  urethritis  in  which  the  larger 
portion  of  the  urethral  mucous  membrane  has  returned 
to  its  normal  condition,  the  pathological  process  being 
limited  to  one  or  more  circumscribed  areas.  The  secre- 
tion in  these  cases  is  slight,  and  may  not  be  apparent 
except  as  shreds  in  the  urine.  It  is  evident  that  a  case 
of  the  second  may  temporarily  be  transformed  into  one 
of  the  first  class,  as  a  result  of  sexual  or  other  excesses 
or  of  active  local  treatment. 

Treatment  of  Cases  of  the  First  Class. — In  these  cases 
the  discharge,  the  pus  in  the  urine,  or  the  subjective 
symptoms  show  that  a  considerable  portion  of  the  ure- 


428      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

tbral  mucous  membrane  is  inflamed,  or  at  least  irritated 
and  congested,  and  that  all  instrumentation  of  the  ure- 
thra should  be  avoided.  The  treatment  should  corre- 
spond with  that  given  for  the  late  stages  of  gonorrhoea. 
Internally,  copaiba,  sandalwood,  and  cubebs  give  good 
results.  In  posterior  urethritis  boric  acid  and  salol  are 
often  of  value,  and  may  be  given  in  addition  to  one  or 
more  of  the  above-named  remedies.  Methylene  blue, 
given  in  I-  or  2-grain  capsules  four  times  a  day,  is  often 
effective.  Mixed  infections  of  the  deep  urethra  and  also 
of  the  bladder  frequently  occur,  and  are  almost  always 
benefited  by  urotropin,  in  doses  of  from  3  to  8  grains 
four  times  a  day.  Local  treatment  should  be  limited  to 
the  use  of  injections  or  irrigations. 

The  injections  used  may  be  those  recommended 
for  the  declining  stages  of  gonorrhoea,  though  it  may 
be  necessary  gradually  to  increase  their  strength. 
Many  other  preparations  are  recommended,  and  some- 
times prove  serviceable  in  the  treatment  of  chronic  ure- 
thritis. Among  them  are  sulphate  of  copper  and  chlo- 
ride of  zinc.  Each  of  these  may  be  used  in  strengths 
varying  from  one-fourth  of  a  grain  to  a  grain  in  an  ounce 
of  distilled  water.  Alcohol  or  glycerine,  or  both,  may  be 
added  to  any  of  these  preparations,  the  quantity  added 
being  small  at  first  and  gradually  being  increased  if  it 
does  not  irritate  the  urethra.  Instead  of  alcohol  an 
astringent  wine  may  be  used.  The  practitioner  is  again 
warned  against  the  folly  of  using  too  many  injections. 
He  will  obtain  the  best  results  if  he  limits  himself  to 
two  or  three  preparations  with  which  he  has  become 
thoroughly  familiar.  He  can  easily  vary  their  strength 
and  frequency  of  application  to  suit  the  needs  of  each 
case.  Strong  injections  should  not  be  used  until  weaker 
ones,  after  faithful  trial,  fail  to  do  good.  The  solutions 
used  should  always  be  weak  at  first,  and  if  necessary 
gradually  be  increased  in  strength,  and  injections  strong 
enough  to  produce  burning  or  smarting  sensations  in 
the    urethra    should    not    be    used.     Nor   should    it    be 


CHRONIC   URETHRITIS.  429 

forgotten  that  an  injection,  although  not  producing  a 
smarting  sensation,  may,  nevertheless,  damage  the  ure- 
thra. The  effect  of  an  injection  can  best  be  judged  by- 
watching  the  effect  upon  the  discharge,  or  upon  the 
number  of  pus-cells  and  shreds  in  the  urine. 

It  should  be  remembered  that  often  the  last  drop  of 
mucus  will  not  disappear  from  the  meatus  until  after  the 
injection  has  been  stopped  and  the  mucous  membrane  has 
had  time  to  recover  from  the  stimulating  effects  of  local 
treatment.  If,  after  using  an  injection  for  two  or  three 
weeks,  the  discharge  is  reduced  to  a  drop  or  two,  the 
injection  should  be  used  with  gradually  diminishing  fre- 
quency for  a  week  or  two  and  then  be  stopped,  and  the 
patient  should  be  allowed  a  fortnight  without  local  treat- 
ment. If  the  slight  discharge  or  the  shreds  in  the  urine 
persist,  the  case  is,  so  far  as  the  anterior  urethra  is  con- 
cerned, one  of  the  second  class,  and  is  ready  for  exam- 
ination and  treatment  with  instruments. 

Injections  made  with  a  gonorrhceal  syringe  will,  of 
course,  reach  only  the  anterior  urethra.  If  posterior 
urethritis  be  present  in  such  degree  that  the  second 
glass  of  urine  is  clouded  with  pus,  the  inflammation 
should  be  reduced  as  far  as  possible  before  beginning 
the  use  of  sounds  and  instruments.  This  result  can 
usually  be  accomplished  by  means  of  internal  treat- 
ment, aided,  in  some  cases,  by  deep  irrigation.  The  best 
method  of  irrigating  the  deep  urethra  is  that  already  de- 
scribed as  "  Janet's  method."  The  anterior  urethra 
should  always  be  cleansed  first,  so  that  pus  or  shreds 
that  have  been  present  in  this  portion  will  not  be  carried 
into  the  pars  posterior  during  the  subsequent  steps  of 
the  operation. 

Instead  of  a  short  tube  a  soft  catheter  may  be  used. 
After  washing  out  the  anterior  urethra  the  tip  of  the 
catheter  may  be  passed  to  the  membranous  or  the  begin- 
ning of  the  prostatic  urethra ;  the  fluid  will  then  fill  the 
deep  urethra  and  pass  into  the  bladder.  The  point  is 
known  to  have  entered  the  membranous  portion  by  the 


430      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

yielding  of  the  compressor  urethrae  muscle,  which  can 
generally  be  recognized  by  the  operator,  or  by  the  fact 
that  the  irrigating  fluid  no  longer  escapes  from  the 
meatus ;  or  the  catheter  may  be  detached  from  the  irri- 
gating apparatus  and  passed  into  the  bladder  and  slowly 
withdrawn  until  the  urine  ceases  to  flow,  and  the  tip  is 
thus  known  to  be  in  the  deepest  portion  of  the  prostatic 
urethra.  The  catheter  should  be  lubricated  with  glycerin, 
or  other  non-oily  substance,  since  oil  or  vaseline  would 
coat  the  mucous  membrane  and  interfere  with  the  action 
of  the  solution.  Instead  of  a  fountain  syringe  or  irri- 
gator with  an  elevated  receptacle,  an  Ultzmann   hand 


T 

Fig.  26. — Ultzmann's  syringe. 

syringe  with  a  capacity  of  4  or  5  ounces  may  be  used 
(Fig.  26). 

Of  the  many  solutions  used  for  irrigation  of  the  deep 
urethra,  the  following  are  among  the  best :  Nitrate  of 
silver  (1  :  20,000  to  I  :  500  of  distilled  water),  bichloride 
of  mercury  (1  :  80,000  to  I  :  10,000),  sulphate  or  acetate 
of  zinc  (1  :  1000  to  I  :  100),  and  permanganate  of  potash 
(1  :  20,000  to  I  :  1000).  Ultzmann's  method  was  as 
follows :  There  was  prepared  a  solution  containing 
I  part  each  of  crude  alum,  zinc  sulphate,  and  carbolic 
acid  in  500  parts  of  water.  For  the  first  irrigation 
this  solution  was  diluted  with  three  times  its  bulk 
of  warm  water.  If  well  borne,  the  strength  was 
gradually  increased  until  at  the  end  of  three  or  four 
days  or  a  week  the  solution  was  used  in  full  strength. 
This  preparation  was  then  changed  for  a  solution  of 
permanganate  of  potash,  1  :  20,000,  gradually  increased 
in    strength    up    to    1  :  1000.       Lastly,    a    solution  of 


CHRONIC   URETHRITIS.  43  I 

nitrate  of  silver,  1  :  2000,  was  substituted,  and  was 
gradually  increased  in  strength  to  1  :  1000.  Irrigations 
were  given  daily. 

As  with  injections,  weaker  solutions  should  be  tried 
first,  and  the  strength  gradually  be  increased  when 
necessary  and  when  the  resulting  irritation  of  the 
urethra  is  slight.  They  may  be  used  at  first  about 
once  in  three  days,  but  when  the  urethra  becomes  ac- 
customed to  the  process  and  shows  a  milder  reaction 
after  it,  they  may  be  given  every  other  day  or  even  daily. 
At  each  irrigation  about  4  ounces  of  the  warmed  solu- 
tion should  be  used  in  the  posterior  urethra,  after 
the  anterior  urethra  has  been  cleansed  thoroughly. 
The  bladder  should  be  about  half  full,  that  the  urine 
may  dilute  the  solution  sufficiently  to  prevent  injury 
to  the  bladder-walls.  It  is  desirable  to  have  the  patient 
retain  his  urine  for  some  time  after  the  irrigation,  that 
the  medicament  may  be  left  as  long  as  possible  in 
contact  with  the  mucous  membrane  of  the  urethra.  In 
many  cases  better  results  are  obtained  if  the  bladder  be 
emptied  first,  and,  after  cleansing  the  anterior  urethra, 
at  least  a  pint  of  a  weaker  solution  be  allowed  to  flow 
over  the  deep  urethra  into  the  bladder.  After  being  re- 
tained a  few  minutes,  or  not  at  all  if  it  causes  discomfort, 
it  is  allowed  to  escape,  thus  coming  in  contact  with  the 
diseased  area  a  second  time. 

In  case  both  anterior  and  posterior  urethritis  are 
present,  and  irrigation  is  practised  every  second  or 
third  day,  the  patient  may  use  an  injection  once  or 
twice  a  day.  If  after  two  or  three  weeks  of  such 
treatment  the  subjective  symptoms  disappear,  the  dis- 
charge is  reduced  to  a  drop  or  two  of  mucus,  and  the 
urine  is  clear  but  for  a  few  shreds,  the  irrigations 
and  injections  should  be  given  at  gradually  increasing 
intervals  for  a  week  or  more,  and  then  be  stopped  en- 
tirely. A  week  or  two  of  rest  from  local  treatment  may 
remove  these  last  traces  of  the  disorder ;  if,  however, 
they  persist,   the   case   may  be   considered   one   of  the 


432      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

second  class,  and  treatment  with  instruments  is  then 
proper. 

Treatment  of  Cases  of  the  Second  Class. — In  these 
cases  the  subjective  symptoms,  the  discharge  from  the 
meatus,  and  the  cloudiness  of  the  urine  are  slight  but 
persistent,  and  are  usually  due  to  local  lesions.  In  a 
large  proportion  of  cases  stricture  in  some  form  or 
degree  will  be  found,  and  is  the  most  important  and  first 
lesion  to  be  treated.  In  the  absence  of  stricture  there 
may  be  congested  or  infiltrated  and  thickened  patches 
of  mucous  membrane  or  of  submucous  tissue.  There 
may  be  inflamed  follicles  and  lacunae,  or  small  areas  of 
granulations,  or  superficial  losses  of  tissue.  When  these 
conditions  exist,  they  should  be  sought  for  and  located 
by  means  of  the  steel  sound,  the  bulbous  bougie,  or  the 
urethrometer.  In  some  cases  of  the  torpid  and  persist- 
ent type  no  local  lesions  can  be  found,  but  there  may 
be,  instead,  an  atonic  and  mild  catarrhal  condition  of  a 
considerable  portion  of  the  membrane. 

In  almost  all  cases  of  chronic  urethritis  of  the  second 
class  the  most,  effective  local  treatment  is  found  in  the 
proper  use  of  the  steel  sound.  The  dilation  of  the 
urethra  by  the  full-sized  steel  sound  opens  and  smooths 
out  the  folds  and  lacunae  of  the  mucous  membrane,  thus 
freeing  them  of  retained  secretions  which  the  stream  of 
urine  does  not  reach.  The  pressure  exerted  by  the 
sound  empties  inflamed  follicles  of  their  contents  and 
stimulates  the  process  of  absorption  in  the  areas  of  con- 
gestion and  thickening,  while  the  effect  of  the  cold  steel 
upon  granulating  patches  and  upon  an  atonic,  catarrhal 
condition  of  the  mucous  membrane  is  stimulating  and 
often  beneficial.  The  best  instrument  to  use  is  a 
smooth,  blunt  steel  sound  of  the  largest  size  that  will 
pass  the  meatus  without  stretching  it.  It  is  not  neces- 
sary, as  a  rule,  to  cut  the  meatus  unless  the  latter  be 
abnormally  small.  If  this  be  the  case,  the  narrowing  is 
usually  due  to  a  thin  band  of  tissue  at  the  lower  end  of 


CHRONIC   URETHRITIS.  433 

the  aperture ;  behind  the  band  is  a  small  pouch  that 
can  be  detected  by  the  point  of  a  probe  introduced  into 
the  urethra  for  half  an  inch  and  drawn  forward  along  the 
floor.  This  condition  may  be  the  sole  cause  of  the  per- 
sistence of  a  discharge,  since  it  interferes  with  the  free 
drainage  of  the  urethra.  In  this  case  all  that  is  neces- 
sary is  simple  incision  of  the  thin  band  of  tissue,  fol- 
lowed by  the  use  of  sounds  for  a  few  days  to  keep  the 
cut  edges  from  reuniting. 

Any  incision  of  the  meatus  should  be  made  down- 
ward in  the  median  line,  and  not  upward,  and  should 
be  done  slowly  and  with  great  care,  not  with  a  single 
stroke.1  Since  the  meatus  is  often  normally  the  nar- 
rowest point  of  the  urethra,  it  is  sometimes  necessary 
to  enlarge  it  in  order  to  introduce  larger  instru- 
ments for  the  treatment  of  the  deeper  parts.  But  this 
little  operation,  simple  as  it  is,  leaves  the  meatus  in 
a  condition  not  natural  to  it,  and  therefore  cannot  be 
entirely  harmless.  The  physician  who  treats  many 
obstinate  cases  of  chronic  urethritis  will  see  a  proportion 
of  them  in  which  the  lips  of  a  freely  cut  meatus  gape 
widely  and  expose  a  considerable  portion  of  urethral 
membrane  which  under  normal  conditions  would  be 
covered  and  protected.  In  this  condition  may  be  found 
the  cause  of  not  a  few  persistent  urethral  discharges. 
The  surgeon  who  recognizes  these  facts  will  not  look 
upon  the  mutilation  of  the  meatus  as  a  simple  and 
harmless  procedure,  to  be  adopted  as  a  matter  of  con- 
venience, but  will  reserve  the  operation  for  those  cases 
in  which  the  meatus  is  abnormally  small,  or  in  which 
the  condition  of  deeper  portions  of  the  urethra  necessi- 
tates the  use  of  instruments  too  large  to  pass  the  normal 
meatus.  In  many  instances  incision  of  the  meatus  may 
be  avoided  by  the  use  of  Keyes'  double  taper  steel  sound 
(Fig.  27),  or  of  the  Weiss  sound  (Fig.  28).  The  latter  is 
of  service  in  the  anterior  urethra  only. 

Before  introducing  the  sound  it  should  be  lubricated, 

1  See  Meatotomy. 

28 


434      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

but  not  warmed.      It  should  be  introduced  with   great 
gentleness,   allowed  to   remain   from   a  few   seconds   to 


Tl&VKUO^O- 


Fig.  27. — Keyes'  double  taper  sound. 


fifteen  minutes,  and  as  gently  withdrawn.     If  the  lesions 
to  be  treated  are  in  the  posterior  urethra,  the  tip  of  the 


Fig.  28.— Weiss'  sound. 

sound  will  be  carried  on  into  the  bladder.  If  the  lesions 
are  limited  to  the  pars  anterior,  the  sound  should  not  be 
passed  further  than  necessary  to  affect  the  lesions,  and  a 
short,  blunt  sound  is  often  more  convenient  than  a 
curved  one.  Usually  there  is  little  gained  in  passing 
sounds  oftener  than  once  in  three  days,  though  they 
may  be  used  more  frequently  in  the  pars  anterior. 

The  use  of  the  cold  sound  is  especially  valuable 
in  disease  of  the  pars  posterior  complicated  by  chronic 
prostatitis,  prostatorrhcea,  or  sexual  neurasthenia.  In 
these  cases  the  sound  may  be  introduced  as  often  as 
every  second  day,  providing  the  irritation  or  reaction 
resulting  from  its  passage  subsides  within  a  few  hours ; 
and  when  the  urethra  tolerates  well  the  presence  of 
the  sound,  it  may  be  held  in  position  from  a  few 
seconds  to  fifteen  minutes  before  withdrawing.  In 
place  of  the  ordinary  sound  the  cold  sound  of 
Winternitz  (Fig.  29)  may  be  used.  This  instrument 
is  a  metal  catheter  closed  at  its  vesical  end  and 
divided  into  two  channels  by  a  longitudinal  septum. 
Just  within  the  tip  the  two  channels  communicate,  while 
externally  they  connect  in  a  fork-shaped  end  with  two 
rubber  tubes.  Water  injected  into  one  tube  flows  out 
of  the  other  after  passing  through  the  entire  length  of 


CHRONIC  URETHRITIS.  435 

the  catheter  twice.     If  the  end  of  one  tube  be  immersed 
in  water  and  suction  be  made  upon  the  other  end,  the 


Fig.  29. — Winternitz's  psychrophor  (cooling  sound). 

water  will  flow  through  the  catheter  as  in  a  siphon.  It 
is  well  to  begin  with  water  at  the  temperature  of  the 
room,  and  to  cool  it  gradually  until  eventually  ice-water 
may  be  used.  The  application  should  last  from  five  to 
fifteen  minutes,  and  may  be  given  about  every  second 
day. 

Another  method  of  treating  disease  of  the  pars  pos- 
terior, highly  recommended  by  Keyes  and  others,  lies 


Fig.  30. — Keyes-Ultzmann  syringe  (Tiemann). 


in  the  use  of  deep  injections.  The  best  instrument  for 
the  purpose  is  Keyes'  modification  of  Ultzmann's  deep 
urethral  injector  (Fig.  30).  The  tube  of  the  catheter  is 
capillary  in  size  and  open  at  the  end.  Before  introduc- 
ing the  instrument  the  catheter  is  completely  filled  with 


Fig.  31. — Guyon's  deep  urethral  syringe. 


the  liquid,  so  that  for  every  drop  forced  out  of  the  barrel 
of  the  syringe  an  equal  drop  escapes  from  the  tip.     The 


436      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

lesion  to  be  treated  having  been  located,  the  tip  of  the 
syringe  is  carried  to  this  point,  and  from  3  to  10  minims 
of  the  solution  are  deposited  upon  it.  The  best  prepa- 
ration for  this  use  is  a  solution  of  nitrate  of  silver  vary- 
ing in  strength  from  1  to  20  grains  (in  rare  cases 
gr.  xlv)  to  the  ounce.  This  cauterizing  or  "  etching " 
of  the  deep  urethra  is  followed  by  a  more  or  less  violent 
reaction.  The  desire  to  urinate  is  felt  almost  immedi- 
ately, and  for  a  few  hours  tenesmus  and  other  painful 
symptoms  may  be  present.  The  application  should  not 
be  repeated  oftener  than  two  or  three  times  a  week,  and 
never  before  the  irritating  effects  of  the  previous  applica- 
tion have  entirely  disappeared.  Solutions  of  this  strength 
should  not  be  injected  into  any  portion  of  the  anterior 
urethra,  hence  the  operator  must  know  that  the  tip  of 
the  catheter  has  at  least  entered  the  membranous  por- 
tion. With  the  finger  in  the  rectum,  exact  location  of 
the  tip  should  not  be  difficult  to  one  familiar  with  the 
use  of  sounds.  If  in  any  case  the  operator  is  in  doubt, 
he  can  satisfy  himself  by  detaching  the  syringe  from  the 
catheter  and  using  the  latter  in  the  manner  described  for 
deep  irrigation  :  urine  escapes,  if  the  bladder  be  full,  when 
the  tip  of  the  catheter  enters  the  neck  of  the  bladder. 
This  method  in  skilled  hands  is  of  value  in  some  cases, 
but,  as  a  rule,  does  not  give  such  good  results  as  deep 
irrigations. 

Finger  and  others  recommend  the  introduction  of 
lanolin  instead  of  watery  solutions,  and  Tommasoli 
devised  a  syringe  for  the  purpose.  The  piston  within 
the  catheter  is  on  a  flexible  rod  marked  in  decigrams, 
so  that  the  amount  of  the  application  can  be  regulated 
with  accuracy.  One  decigram  of  the  following  solu- 
tion may  be  placed  in  the  deep  urethra  at  each  treats 
ment : 

1^.  Argent,  nitrat,  gr.  xv-3j ; 

Lanolini,  §iij ; 

Ol.  olivar.,  3iss. — M. 


CHRONIC   URETHRITIS.  437 

Sulphate  of  copper  or  creolin  may  be  substituted  for 
the  nitrate  of  silver  in  this  ointment.  Regarding  this 
form  of  medication  Finger  says  :  "  The  lanolin  ointments 
possess  the  advantage  of  adhering  intimately  to  the 
mucous  membrane.  If  fluids,  gelatin,  or  cacao-butter 
bougies  are  introduced,  they  are  washed  out  of  the 
urethra  by  the  first  micturition.  On  the  contrary,  the 
contracting  urethral  walls  compress  the  lanolin  ointment 
after  the  injection  and  press  it  into  the  mucous  mem- 
brane. Micturition  evacuates  only  small  particles  of 
the  ointment ;  these  particles  are  found  in  the  urine  even 
thirty-six  hours  after  injection.  Even  pollutions  do  not 
remove  all  the  ointment  from  the  urethra.  It  therefore 
forms  a  real  urethral  bandage,  and  its  protracted  action 
and  gradual  absorption  have  a  more  favorable  effect 
than  the  ephemerally  acting  solutions.  In  addition,  as 
Professor  Liebreich  kindly  informs  me,  lanolin  is  an 
aseptic  substance." 

The  deep  injection  of  an  aqueous  solution  or  a  lanolin 
ointment  immediately  after  using  the  cold  sound  is 
sometimes  followed  by  excellent  results.  Finger  rec- 
ommends this  combined  treatment  in  old  foci  of  infil- 
tration in  the  pars  posterior  and  in  the  bulb.  For  this 
purpose  he  uses  the  following  ointment : 

1^5.  Potass,  iodid.,  giss  ; 

Iodin.  puri,  gr.  xv; 

Lanolini,  ^iij ; 

01.  olivar.,  3iss. — M. 

Other  methods  of  medicating  the  deep  urethra  have 
been  tried.  Among  those  still  in  use  are  soluble 
bougies,  ointments  introduced  on  grooved  sounds,  and 
the  injection  of  finely  divided  solids  suspended  in  a 
sticky  fluid.  These  methods  are  not  so  serviceable  as 
those  already  given,  and  are  rapidly  falling  into  disfavor. 

Not  infrequently  all  treatment  of  a  posterior  urethritis 
fails  utterly  until  an  unrecognized  chronic  inflammation 


438      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

of  the  prostate  or  seminal  vesicles  is  discovered  and 
properly  treated.  These  subjects  are  considered  in  the 
succeeding  chapters. 

By  means  of  the  endoscope  granulating  patches, 
superficial  ulcers,  areas  of  congestion,  inflamed  folli- 
cles, and  foreign  growths  in  the  urethra  may  be 
brought  into  view,  and  applications  may  be  made 
directly  to  them.  The  most  useful  preparation  is 
nitrate  of  silver  in  solution  varying  from  I  to  20  per 
cent.,  though  it  may  occasionally  be  used  much 
stronger.  Sulphate  of  copper  may  be  used  in  the  same 
manner.  Lugol's  solution  and  other  preparations  of 
iodine,  as  well  as  carbolic  acid  in  varying  strengths, 
alone  or  combined  with  iodine  and  glycerin,  are  ser- 
viceable at  times.  Any  of  the  above  drugs  may  be 
applied  in  the  form  of  lanolin  ointment,  and  iodoform, 
iodol,  aristol,  or  other  powders  may  be  used.  For  the 
application  of  solutions  or  ointments  nothing  is  better 
than  bits  of  cotton  twisted  on  the  ends  of  wires  or  on 
thin  strips  of  wood  such  as  may  be  obtained  from 
match-factories.  Ultzmann  invented  a  brush  apparatus 
for  the  purpose.  The  handle  of  the  brush  can  readily 
be  adjusted  so  that  the  brush  will  reach  only  that  por- 
tion of  membrane  that  projects  beyond  the  rim  of  the 
endoscopic  tube.  After  the  use  of  strong  solutions  the 
surface  should  immediately  be  dried  of  any  surplus,  to 
prevent  its  reaching  other  portions  of  the  membrane ;  to 
lessen  pain,  iodoform  in  powder  or  in  ointment  may  be 
applied.  Applications  may  be  made  from  once  in  three 
or  four  days  to  once  in  a  week  or  two,  depending  on  the 
strength  of  the  solutions  used,  the  sensitiveness  of  the 
patient,  and  the  amount  of  irritation  that  follows. 
When  the  condition  begins  to  improve,  the  intervals 
between  treatments  should  gradually  be  lengthened. 

In  general,  with  reference  to  local  treatment  of  ure- 
thritis, it  should  be  remembered  that  the  use  of  an  injec- 
tion or  an  instrument  in  the  urethra  is  followed  by  more 
or  less  reaction  and  irritation.     The  reaction  may  appear 


CHRONIC   URETHRITIS.  439 

in  the  form  of  an  increased  discharge  from  the  meatus, 
in  case  the  pars  anterior  is  alone  affected,  or  in  frequency 
of  micturition  and  tenesmus  when  the  pars  posterior  also 
has  been  treated.  The  symptoms  usually  appear  at  once, 
increase  for  a  few  hours,  and  then  rapidly  subside.  Irri- 
gation, deep  injection,  or  instrumentation  of  the  urethra 
should  not  be  repeated  until  all  evidences  of  a  reaction 
from  the  previous  treatment  have  been  absent  for  twenty- 
four  hours.  Rough  treatment  of  the  urethra  is  never 
permissible.  All  instruments  should  be  used  with  great 
care  and  gentleness.  Mild  methods  and  preparations 
should  always  be  used  in  beginning  the  management  of 
any  case.  If  these  methods  prove  insufficient,  more  ener- 
getic measures  may  gradually  be  adopted.  During  local 
treatment  the  sensitiveness  of  the  urethra  becomes  dulled, 
and  good  results  follow  the  employment  of  remedies 
which,  if  used  at  first,  would  produce  violent  inflammation. 

As  a  rule,  the  first  micturition  which  follows  a  local 
treatment  of  the  urethra  is  attended  by  more  or  less 
smarting  and  burning,  and,  when  possible,  should  be  de- 
layed for  a  number  of  hours,  for  when  urination  follows 
too  closely  the  use  of  instruments,  the  much-to-be-desired 
rest  of  the  recently  treated  parts  is  prevented,  and  often 
the  amount  of  irritation  and  reaction  is  increased ;  after 
local  applications  the  immediate  passage  of  urine  removes 
some  of  the  remedy  and  interferes  with  its  action.  In 
consequence,  local  treatment  of  the  urethra  should  usually 
be  preceded  by  evacuation  of  the  bladder.  The  excep- 
tions to  this  rule  are  found  in  irrigation  of  the  deep  ure- 
thra with  stronger  solutions,  for  which  procedure  the 
bladder  should  contain  half  a  pint  or  more  of  urine, 
and  occasionally  in  beginning  the  use  of  deep  injections, 
when  the  immediate  passage  of  urine  may  be  desired  to 
lessen  the  action  of  a  remedy  whose  effect  threatens  to 
be  too  severe. 

If  improvement  follows  a  certain  treatment,  it  should 
be  given  with  gradually  diminishing  frequency,  and  should 
finally  be  suspended.     Its  best  effects  will  not  be  appar- 


44-0      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

ent  until  after  the  urethra  has  rested  for  a  couple  of  weeks 
or  more.  If  a  given  treatment  fails  to  do  good,  it  is 
usually  best  to  follow  it  with  a  period  of  rest  before  try- 
ing anything  else. 

Finally,  while  studying  and  making  intelligent  appli- 
cation of  local  measures  the  successful  physician  will  not 
fail  to  keep  a  constant  watch  over  his  patient's  general 
health,  habits,  and  surroundings.  A  careful  regulation 
of  the  sexual  hygiene  is  always  of  the  greatest  impor- 
tance. In  some  instances  no  amount  of  local  treatment 
will  be  successful  until  the  patient's  general  nutrition  and 
general  nervous  condition  be  improved  by  proper  meas- 
ures, such  as  change  of  climate  and  occupation,  rest, 
tonics,  cod-liver  oil,  etc.  Occasionally,  the  mental 
attitude  of  the  patient  presents  the  greatest  obstacle  to 
his  recovery.  Varying  grades  of  melancholia  and  hypo- 
chondriasis are  often  encountered  and  call  for  skilful 
treatment. 

Prognosis. — It  is  evident  that  in  chronic  urethritis  a 
guarded  prognosis  is  necessary,  and  many  factors  must 
be  considered. 

In  the  tubercular,  cachectic,  or  anaemic,  the  future  of 
the  urethritis  depends  largely  on  the  future  health  of  the 
individual. 

In  a  man  who  is  violating  the  laws  of  sexual  and  gen- 
eral hygiene  the  future  course  of  urethritis  will  depend 
chiefly  upon  the  promptness  and  completeness  with 
which  he  changes  his  mode  of  living  to  conform  to  these 
laws. 

Recent  cases  that  have  received  little  treatment  recover 
more  promptly  and  certainly  than  do  older  cases.  Old 
cases  that  have  been  subjected  to  more  or  less  constant 
and  severe  forms  of  treatment  are  among  the  most  in- 
tractable. Such  urethras  can  never  return  fully  to  their 
virgin  condition,  and  such  portions  as  have  been  destroyed 
by  cutting  or  cauterizing  can  never  be  replaced  by  nor- 
mal tissue.  It  may  therefore  be  impossible  to  remove 
entirely  the  few  shreds  in  the  urine,  the  drop  of  mucus 


CHRONIC   URETHRITIS.  44 1 

at  the  meatus,  or  the  sensitiveness  of  the  prostatic  ure- 
thra that  necessitates  slight  increase  over  the  normal  in 
the  frequency  of  urination,  though  in  all  other  respects 
recovery  may  be  complete. 

Disease  of  the  pars  anterior  can  usually  be  cured,  while 
lesions  that  persist  cause  no  serious  symptoms,  if  excep- 
tion be  made  of  the  extensive  and  deforming  cicatrices 
which  sometimes  follow  ill-advised  operations. 

Disease  of  the  pars  posterior  is  less  accessible  to  treat- 
ment, and  if  complicated  by  prostatitis,  seminal  vesiculitis, 
and  neurasthenic  symptoms  the  prognosis  is  less  favor- 
able, but  with  time,  patience,  and  proper  management 
most  of  the  cases  recover. 

If  stricture  be  the  cause  of  a  urethritis,  the  prognosis 
of  the  latter  will  depend  on  the  nature  and  location  of 
the  former. 

In  well-managed  cases  of  chronic  urethritis  the  con- 
tagious element  gradually  disappears,  and  in  most — if 
not  in  all — may  be  removed  entirely.  The  time  required 
for  its  complete  disappearance  varies  from  two  or  three 
months  to  a  year.  Exceptional  cases  may  require  two 
or  three  years. 


COMPLICATIONS  OF  URETHRITIS. 


EPIDIDYMITIS. 


With  the  exception  of  posterior  urethritis,  epididymi- 
tis is  the  most  frequent  complication  of  gonorrhoea.  It 
occurs  in  from  6  to  15  per  cent,  of  all  cases  of  acute 
gonorrhoea,  and  it  usually  makes  its  appearance  during 
the  third  or  fourth  week  of  that  disease.  It  frequently 
begins  as  late  as  the  eighth  week,  and  it  may  occur 
much  later,  though  most  of  the  cases  appearing  some 
months  or  years  after  an  attack  of  gonorrhoea  are  un- 
doubtedly due  to  an  exacerbation  of  a  chronic  urethritis, 
to  stricture,  or  to  other  causes.  It  is  also  found  as  early 
as  the  second  week,  and  cases  are  reported  as  beginning 
during  the  first  week,  of  gonorrhoea. 

The  epididymitis  is  usually  single,  the  left  testicle  being 
involved  somewhat  more  frequently  than  the  right.  When 
both  testicles  are  implicated,  the  second  follows  several 
days  or  weeks  after  the  first,  simultaneous  epididymitis 
of  both  testicles  being  very  rare.  The  first  attack  is 
usually  acute,  and  predisposes  the  patient  to  the  disease, 
which  may  thus  become  chronic.  Occasionally,  in 
cachectic  subjects  or  when  due  to  stricture  or  chronic 
urethritis,  it  may  be  subacute  from  its  origin.  It  is 
usually  accompanied  by  inflammation  of  the  tunica 
vaginalis,  and  less  frequently  by  orchitis. 

Etiology. — Epididymitis  occurs  during  acute  gonor- 
rhoea without  other  apparent  cause.  It  is  more  frequent 
in  neglected  and  poorly-treated  cases  than  in  those 
treated  in  accordance  with  the  hygienic  and  other  rules 
given  for  the  treatment  of  gonorrhoea.  Its  development 
is  favored  by  local  treatment  in  the  acute  stages  of  gon- 
orrhoea.     Any  of  the  causes   described  as  capable  of 

442 


EPIDID  YMITIS.  443 

producing  an  exacerbation  of  the  urethritis  or  irritation 
of  the  urethra  may  increase  the  danger  of  epididymitis. 
It  is  probably  always  preceded  by  inflammation  of  the 
pars  posterior,  from  which  position  the  inflammation 
travels  readily  and  continuously  through  the  ejaculatory 
ducts  and  the  vas  deferens  to  the  epididymis.  Evidences 
of  inflammation  of  these  intermediate  parts  are  often 
wanting,  and  it  is  possible  that  in  some  cases  the  lymph- 
atics convey  the  infection  directly  from  the  deep  urethra 
to  the  epididymis ;  or  the  irritating  agent  may  yet  be 
found  in  toxins  and  not  always  in  the  micro-organisms 
themselves.  Both  gonococci  and  pus  cocci  have  been 
found  in  the  pus  of  a  suppurating  epididymitis. 

Some  individuals,  especially  those  of  a  gouty  or  rheu- 
matic diathesis,  are  very  susceptible  to  the  disease,  while 
others  seem  proof  against  it,  despite  neglect,  reckless  liv- 
ing, and  poor  treatment.  One  attack  always  predisposes 
to  another.  It  occurs  in  subacute  and  chronic  (also  acute) 
forms  in  chronic  gonorrhoea  and  in  stricture,  especially 
when  these  affections  have  been  aggravated  by  ex- 
cessive or  improper  treatment,  disordered  living,  violent 
exercise,  etc.  Finally,  epididymitis  may  occur  inde- 
pendently of  urethral  disease,  as  a  result  of  traumatism, 
exposure  to  cold,  or  possibly  from  prolonged  sexual  ex- 
citement. More  frequently  the  cold,  sexual  excitement, 
or  other  cause  of  local  congestion  serves  merely  to  re- 
new activity  in  an  unrecognized  focus  of  disease  left  by 
a  former  gonorrhoea,  in  the  seminal  vesicles,  prostate,  or 
some  portion  of  the  urethra.  From  such  a  focus,  infec- 
tion of  the  epididymis  can  easily  occur. 

Symptoms. — In  observant  and  sensitive  patients,  and 
especially  if  the  previous  subjective  symptoms  of  gonor- 
rhoea have  been  slight,  inflammation  of  the  epididymis 
is  usually  preceded  by  prodromal  symptoms,  such  as 
slight  chills,  fever,  and  malaise,  with  vague,  uneasy  sen- 
sations or  slight  pain  in  the  groin  radiating  to  the  kid- 
neys and  the  testicle.  Occasionally  the  inguinal  pain 
is  severe,  with  possibly  some  nausea  and  faintness ;  the 


444      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

cord  is  tender  and  feels  as  though  it  were  suspending  a 
heavy  weight ;  or  there  may  be  a  sensation  of  pressure 
in  the  perineum,  with  vesical  tenesmus  and  difficulty  in 
urination.  Less  frequently,  inflammation  and  swelling 
of  the  cord  are  recognized  for  several  days  preceding  an 
epididymitis ;  and  in  rare  instances  the  process  is  limited 
to  the  cord. 

In  unobservant  individuals  and  in  those  already  suffer- 
ing considerable  inconvenience  and  distress  from  gonor- 
rhoea the  prodromal  symptoms  frequently  pass  un- 
noticed. In  such  cases  the  first  recognized  evidence  of 
the  complication  is  usually  a  sudden  decided  pain  in  the 
affected  testicle.  If  examined  at  this  time,  some  por- 
tion of  the  epididymis,  usually  the  globus  minor,  is 
found  to  be  slightly  swollen  and  very  tender.  During 
the  next  twenty-four  hours  the  pain  and  swelling  in- 
crease rapidly;  the  entire  epididymis  soon  becomes  in- 
volved, and  can  be  felt  as  an  irregular,  well-defined, 
moderately  firm,  half-moon-shaped  tumor  enclosing  the 
superior,  posterior,  and  inferior  borders  of  the  testicle. 
It  is  very  painful,  especially  when  the  testicle  is  allowed 
to  hang  without  support,  and  is  exceedingly  tender  to 
the  touch.  Under  favorable  circumstances  or  with  good 
treatment  the  disease  may  progress  no  further,  and  after 
a  few  days  the  symptoms  will  begin  to  subside :  this 
result  is  not  common  even  with  the  best  treatment. 

More  frequently  the  inflammation  extends  from  the 
epididymis  to  the  tunica  vaginalis,  which  becomes  more 
or  less  distended  with  fluid,  thus  adding  greatly  to  the 
swelling  and  pain  and  partially  or  wholly  obscuring  the 
outline  of  the  epididymis  and  testicle.  The  testicle 
proper  becomes  engorged  and  distended  with  blood,  and 
occasionally  true  orchitis  (which  terminates  in  resolution), 
with  its  intense  and  characteristic  pain,  may  be  present. 
The  loose  tissues  of  the  scrotum  become  inflamed,  cedem- 
atous,  and  swollen,  sometimes  forming  irregular,  thick- 
ened tumors  that  may  be  carelessly  taken  for  the  inflamed 
testicle  itself.     The  testicle  with  its  epididymis  and  their 


EPIDID  YMITIS.  445 

coverings  thus  form  an  irregular  or  oval  tumor  that  may- 
become  larger  than  a  man's  fist,  reddened,  hot,  exceed- 
ingly painful,  and  tender.  The  cord  may  become  swollen 
and  very  painful,  often  drawing  the  testicle  up  toward  the 
groin  ;  in  rare  instances  it  becomes  partly  strangulated  in 
the  inguinal  canal,  resulting  in  intense  pain,  collapse, 
and  all  the  symptoms  common  to  strangulation  with  in- 
flammation. 

The  intensity  of  the  symptoms,  however,  varies  greatly 
in  different  cases.  The  swelling  may  be  limited  to  a  part 
or  all  of  the  epididymis,  which  is  more  or  less  indurated 
and  tender,  or  it  may  be  increased  by  fluid  in  the  tunica 
vaginalis.  This  fluid  may  be  scanty  in  quantity  and  may 
serve  merely  to  form  a  fluctuating  tumor  which  but  par- 
tially obscures  the  outline  of  the  testicle  and  epididymis, 
or  it  may  be  sufficient  to  forcibly  distend  the  cavity, 
forming  a  tense,  exceedingly  painful  tumor  which  con- 
ceals entirely  all  traces  of  the  enclosed  structures.  Swell- 
ing and  infiltration  of  the  scrotal  tissues  may  be  slight, 
but  they  are  usually  marked  and  are  often  sufficient  to 
make  an  examination  of  the  deeper  parts  impossible. 
As  a  result  of  ill-fitting  dressings,  swelling  of  the  scro- 
tum may  be  pronounced  in  cases  that  are  otherwise 
mild. 

The  pain  in  epididymitis  varies  greatly,  but  in  acute 
cases  it  is  usually  intense.  The  organ  is  very  sensitive, 
and  the  slightest  pressure  upon  it  causes  the  patient  to 
feel  nauseated  and  faint.  Without  proper  support  for  the 
testicle  walking  is  often  impossible.  Absolute  rest  and 
support  of  the  scrotum  in  one  groin  or  over  the  pubis 
lessens,  but  does  not  entirely  remove,  the  pain.  If  there 
be  much  inflammation  of  the  testicle  proper  or  strangu- 
lation of  the  cord — both  uncommon  occurrences — posi- 
tion has  little  influence  on  the  pain,  which  is  even  more 
intense  than  in  epididymitis,  and  it  may  be  compared  to 
that  of  renal  colic.  A  similar  but  less  severe  grade  of 
pain  is  produced  when  the  tunica  vaginalis  is  greatly  dis- 
tended, but  usually  the  most  tender  part  is  the  epididy- 


446      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

mis,  which  can  thus  be  located  by  palpation  even  through 
a  swollen  and  cedematous  scrotum. 

The  course  of  the  disease  varies  considerably,  being, 
as  a  rule,  much  shorter  and  more  even  when  the  parts 
are  put  at  rest  and  given  proper  treatment  than  in  cases 
in  which  such  rest  and  good  management  cannot  be 
obtained.  It  is  further  influenced  by  the  idiosyncrasies 
and  general  health  of  the  patient.  In  an  acute  case  the 
symptoms  usually  increase  rapidly  in  severity  for  three 
or  four  days  or  a  week,  remain  stationary  for  a  few  days 
more,  and  then  decline,  so  that  at  the  end  of  ten  days 
or  two  weeks  from  the  beginning  the  pain  is  practically 
gone  and  the  swelling  is  limited  chiefly  to  the  epi- 
didymis, some  portions  of  which  are  still  indurated  and 
tender.  An  uncomfortable  sense  of  weight  and  sore- 
ness may  remain  for  some  time. 

From  the  beginning,  if  the  patient  be  kept  on  his 
back  and  the  scrotum  be  well  supported,  the  pain  usually 
subsides  rapidly,  and  it  may  become  slight  before  the 
swelling  has  begun  to  disappear ;  but  if  he  sit  or  stand 
and  allow  the  testicle  to  depend,  the  pain  promptly  re- 
turns. As  the  pain  subsides  the  patient  often  thinks 
himself  able  to  get  up  and  return  to  his  business,  but  a 
few  hours  or  a  day  of  ordinary  activity  may  send  him 
to  bed  with  the  pain  and  swelling  nearly  as  severe  as 
before.  Even  at  the  end  of  two  weeks,  when  he  seems 
to  be  practically  well,  if  he  is  very  active  and  fails 
properly  to  support  the  testicle,  a  relapse  may  be  ex- 
pected. Relapses  are  not  uncommon,  and,  while  less 
severe  than  the  first  attack,  may  prolong  the  disorder 
indefinitely  and  result  in  a  permanent  induration  of  the 
globus  minor  or  major.  As  a  rule,  the  globus  minor, 
or  less  commonly  the  globus  major,  remains  more  or 
less  swollen,  indurated,  and  tender  for  some  weeks; 
while  the  last  traces  of  induration  disappear  gradually 
in  the  course  of  months  or  years,  or  persist  permanently 
in  the  form  of  a  hard,  insensitive  nodule. 

For  a  few  days  during  the  height  of  the  attack  there 


EP1DID  YMITIS.  447 

is  usually  some  fever  with  its  attending  symptoms  ;  such 
constitutional  disturbances  are  usually  mild,  but  occa- 
sionally they  are  quite  severe.  The  gonorrhoeal  dis- 
charge, which  commonly  diminishes  with  or  just  pre- 
vious to  the  appearance  of  the  swelling,  may  disappear 
entirely,  but  it  returns  when  the  swelling  subsides. 

Subacute  attacks  occasionally  complicate  stricture  or 
gleet.  The  symptoms  come  on  more  slowly,  are  much 
less  severe  than  in  the  acute  form,  and  are  usually  con- 
fined to  the  epididymis  or  some  portion  of  it  and  to  the 
cord.  The  testicle,  the  tunica  vaginalis,  and  the  scrotum 
are  not  at  all  or  but  slightly  involved,  and  constitutional 
symptoms  are  wanting.  The  epididymis,  and  frequently 
the  cord,  is  somewhat  swollen,  tender,  and  sensitive,  but 
a  well-fitting  suspensory  or  other  support  usually  enables 
the  patient  to  attend  to  his  usual  work  without  much 
discomfort,  though  violent  exercise  must  be  avoided. 
As  in  gonorrhoea,  the  gleety  discharge  disappears  dur- 
ing the  swelling,  to  return  as  the  latter  subsides. 

As  a  result  of  repeated  subacute  attacks  or  of  relapses 
in  acute  epididymitis,  the  inflammation  may  become 
chronic.  Portions  of  the  epididymis  are  then  constantly 
swollen,  thickened,  and  tender,  simulating  tuberculosis 
of  the  organ,  except  that  the  nodular  enlargements  are 
smoother  and  less  irregular  in  outline,  and  that  slight 
causes  suffice  to  produce  a  subacute  inflammation  of  the 
entire  body  of  the  epididymis.  The  cord  and  the  con- 
nective tissue  about  it  may  also  be  swollen,  infiltrated, 
and  sensitive,  and  may  be  the  seat  of  neuralgic  pains. 
Exceptionally  there  is  chronic  suppuration  in  portions 
of  the  inflamed  tissues. 

Diagnosis. — The  characteristic  symptoms  appearing 
during  the  course  of  a  gonorrhoea  usually  render  the 
diagnosis  easy.  Orchitis,  the  only  other  disorder  for 
which  it  might  be  mistaken,  is  rare  and  is  not  commonly 
associated  with  urethral  inflammation,  but  is  caused  by 
injuries,  mumps,  cold,  and  constitutional  disorders.  The 
swelling  in  orchitis  involves  the  testicle  proper,  comes  on 


448      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

more  slowly,  and  forms  a  smaller  tumor  which  is  oval, 
smooth,  peculiarly  hard  and  tender,  and  not  obscured 
by  fluid  in  the  tunica  vaginalis.  The  pain  is  more  in- 
tense and  unbearable  than  in  epididymitis,  and  is  not 
influenced  by  position.  Its  course  is  slower,  and  it  may 
result  in  destruction  of  portions  or  of  all  of  the  testicle 
through  atrophy,  suppuration,  or  gangrene. 

Cases  have  been  reported  in  which  epididymitis  of 
an  undescended  or  abnormally  situated  testicle  has  been 
mistaken  for  strangulated  hernia,  etc.  Such  an  error 
can  be  avoided  by  an  examination  of  the  scrotum,  which 
would  show  the  absence  of  one  testicle.  There  have 
also  been  reported  cases  in  which  the  inflammation  has 
been  limited  to  the  vas  deferens,  with  the  formation  of 
a  rounded  painful  tumor  extending  from  the  ring  to  the 
epididymis.  There  are  on  record  a  few  cases  in  which 
an  ordinary  epididymitis  has  been  preceded  by  partial 
strangulation  of  the  cord,  with  symptoms  suggesting 
strangulated  hernia  or  obstruction  of  the  bowel  with 
peritonitis. 

Treatment. — Since  epididymitis  is  almost  invariably  a 
complication  of  urethral  inflammation,  its  prophylactic 
treatment  lies  in  the  proper  hygienic  and  other  manage- 
ment of  the  primary  disorder.  If  an  individual  has  had 
a  previous  epididymitis,  local  treatment  of  his  gonorrhoea 
should  not  be  attempted  until  the  stage  of  decline  is 
well  established,  and  even  then  with  great  caution.  He 
should  wear,  during  the  course  of  his  gonorrhoea,,  a 
well-fitting  suspensory  bandage,  live  as  quietly  as  pos- 
sible, avoid  active  exercise  (especially  lifting,  jumping, 
dancing,  etc.),  and  all  irritation  of  the  sexual  organs, 
following  faithfully  the  hygienic  rules  given  for  the 
treatment  of  gonorrhoea.  Epididymitis  can  sometimes 
be  prevented  if,  upon  the  first  occurrence  of  pain  or 
of  uncomfortable  sensations  in  the  testicle  or  the  groin, 
the  patient  lie  on  his  back,  with  the  scrotum  elevated 
and  covered  for  a  few  hours  with  hot  applications. 

In  acute  cases  of  epididymitis  the  objects  of  treatment 


EPIDID  YMITIS.  449 

are  to  lessen  the  inflammation  and  pain  and  to  promote 
resolution.  The  essential  requirements  are  complete  rest, 
elevation  and  support  of  the  testicle  and  scrotum,  and  the 
application  of  heat.  A  light  diet  and  simple  laxatives  to 
produce  free  evacuation  from  the  bowels  constitute  the 
only  internal  treatment,  unless  the  condition  of  the  in- 
dividual calls  for  special  medication.  A  tenth  of  a  grain 
of  calomel  every  half  hour,  or  five  grains  of  blue  mass 
at  night,  followed  by  a  saline  in  the  morning,  often  act 
well  in  lessening  the  local  congestion.  In  exceptional 
cases,  morphine  or  other  anodynes  for  pain,  or  antipy- 
retics, such  as  phenacetine  and  antipyrine,  may  be 
called  for.  All  treatment  for  gonorhcea,  except  that 
necessary  to  keep  the  urine  bland,  should  be  suspended. 
The  patient  should  rest  quietly  on  his  back.  The 
scrotum  should  be  covered  completely  with  fomenta- 
tions or  poultices,  and  should  be  supported  care- 
fully, by  means  of  a  sling  or  a  bandage,  in  a  com- 
fortable position  over  the  symphysis  or  in  one  groin. 
The  most  satisfactory  bandage  for  this  purpose  is  the  last 
of  those  recommended  for  dressing  the  organs  during 
gonorrhoea,  as  it  can  easily  be  made  to  fit  a  testicle  and 
its  dressing  of  any  size  or  shape.  Another  simple  device 
is  found  in  a  large  handkerchief  or  napkin  folded  once  to 
form  a  triangle ;  the  middle  of  the  long  (folded)  side  is 
placed  under  the  scrotum,  and  an  end  (acute  angle)  is 
fastened  on  each  side  to  a  belt  made  of  any  convenient 
and  comfortable  material.  The  free  (right)  angle  is 
brought  up  over  the  genitals  and  dressings  and  fastened 
to  the  belt  in  front.  To  keep  the  handkerchief  from 
slipping  upward  it  may  be  necessary  to  sew  to  its  pos- 
terior border  a  narrow  band  that  can  be  pinned  to  the 
belt  behind. 

Heat  is  best  applied  by  means  of  fomentations,  which, 
when  skilfully  employed,  are  more  effective  than  poultices, 
and,  being  light,  are  often  more  comforting  to  the  patient, 
for  in  a  severe  case  the  testicle  may  be  so  sensitive  that 
the  weight  of  a  poultice  cannot  be  tolerated.     They  may 

>        29 


45 O      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

be  made  of  a  number  of  layers  of  gauze,  or  of  from  one  to 
four  thicknesses  of  a  light  white  flannel  faced  with  a  piece 
of  gauze,  linen,  silk,  or  cotton,  which  will  be  less  irritating 
to  the  skin  than  the  flannel.  They  should  be  large 
enough  to  more  than  cover  the  scrotum  completely,  and 
they  should  be  covered  in  turn  by  a  larger  piece  of  oiled 
silk  or  of  rubber  tissue,  which  will  serve  to  retain  the  heat 
and  to  keep  the  clothing  dry.  They  should  be  applied 
as  hot  as  the  patient  can  tolerate  them  with  comfort,  and 
should  be  changed  often  enough  to  keep  them  hot  (once 
in  half  an  hour  or  an  hour.)  Two  sets  of  cloths  are 
necessary,  that  one  may  be  hot  and  ready  for  immediate 
application  when  the  other  is  removed,  as  much  harm 
may  be  done  by  having  the  parts  exposed  to  a  lower 
temperature  while  preparing  the  fomentation.  It  is 
equally  important  that  in  making  changes  the  testicle 
be  moved  or  disturbed  as  little  as  possible.  The  cloths 
may  be  wrung  out  of  simple  hot  water,  but  it  is  better  to 
add  a  teaspoonful  of  boric  acid  to  each  pint  of  water. 

The  inconvenience  of  frequently  changing  fomenta- 
tions and  the  attendant  discomfort  to  the  patient  may 
be  obviated  by  the  use  of  a  "  Baird  Steam  Fomentator  " 
or  similar  device.  Steam  is  generated  in  a  tin  or  copper 
receptacle,  the  cover  of  which  fits  tightly  enough  to 
prevent  the  escape  of  the  steam  at  a  very  low  pressure, 
and  is  perforated  by  a  tube  to  which  may  be  attached 
one  end  of  a  light  rubber  tubing.  A  portion  of  this 
tubing  is  coiled  in  any  desired  shape  and  size  over  the 
compress,  and  the  other  end  carried  into  a  pail  or  other 
receptacle.  The  steam  passes  through  the  coil  and 
keeps  the  fomentation  constantly  hot,  the  water  of  con- 
densation flowing  out  at  the  other  end.  By  regulating 
the  flame  under  the  receptacle  any  desired  temperature 
may  be  maintained.  With  a  little  ingenuity,  a  small  tea- 
kettle and  ten  or  twelve  feet  of  light  rubber  tubing  can 
be  made  to  serve  the  purpose. 

When  fomentations  cannot  be  applied,  an  ordinary 
flaxseed   poultice    may   be    substituted.      This    poultice 


EPIDID  YMITIS.  45  I 

should  be  from  a  quarter  to  half  an  inch  thick,  faced 
with  a  thin  soft  cloth  to  keep  the  wet  meal  from  adhering 
to  the  scrotum,  and  the  whole  should  be  covered  with 
oiled  silk.  Poultices  retain  the  heat  longer  than  fomen- 
tations, and  need  not  be  changed  so  frequently  (every 
hour  or  two). 

In  the  majority  of  cases  a  few  hours  of  the  above  treat- 
ment will  make  the  patient  comfortable  while  he  remains 
quiet.  If  these  measures  do  not  give  relief,  from  \  ounce 
to  I  ounce  of  fine-cut  tobacco  should  be  stirred  thor- 
oughly in  a  pint  of  the  boiling  water  which  is  to  be  used 
for  fomentations  or  poultices.  This  is  a  very  effective 
anodyne,  but  it  may  produce  nausea.  Instead  of  tobacco, 
10  grains  or  more  of  powdered  opium  to  the  pint  of 
water  may  be  used.  Sometimes  sprinkling  the  surface 
of  the  fomentation  or  the  poultice  with  fine-cut  tobacco 
or  with  laudanum  gives  good  results.  Other  anodynes 
may  be  applied,  under  the  poultice,  in  the  form  of  powder, 
liquid,  or  ointment,  but  they  are  rarely  needed.  If  these 
measures  are  not  sufficient,  and  if  the  pain  be  due  to  ex- 
treme distention  of  the  tunica  vaginalis,  puncture  will 
allow  of  escape  of  the  fluid  and  will  give  immediate  relief. 
In  exceptionally  acute  cases,  with  strangulation  of  the 
cord  and  extreme  pain  which  is  not  relieved  by  the  usual 
treatment,  ten  or  more  leeches  may  be  applied  above  the 
groin,  along  the  course  of  the  cord,  followed  by  the  use 
of  hot  water  to  encourage  bleeding:  the  effect  on  the 
pain  is  often  prompt  and  decided. 

In  all  cases  of  epididymitis,  when  the  patient  can  afford 
the  time,  rest  in  the  horizontal  position  and  elevation  of 
the  scrotum  should  be  continued  for  ten  days  or  two 
weeks,  or  until  all  symptoms  have  disappeared  except  a 
small,  tender,  indurated  swelling  of  the  globus  minor. 
The  fomentations  or  poultices  hasten  absorption  of  the 
inflammatory  products,  and  should  be  continued  when 
practicable,  though  after  the  first  few  days,  when  the 
symptoms  have  begun  to  subside,  they  may  be  replaced 
by  a  more  convenient  and  nearly  as  efficient  dry  dressing 


452      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

formed  by  wrapping  the  scrotum  in  a  layer  of  wool  and 
covering  all  closely  with  an  impervious  covering  of  oiled 
silk  or  of  rubber  tissue.  The  heat  and  moisture  natural 
to  the  parts  are  thus  retained,  forming  what  is  known  as  a 
"  dry  poultice." 

When  a  patient  with  acute  epididymitis  refuses  to  go 
to  bed  for  a  few  days,  other  methods  may  be  tried  ;  but 
he  should  first  understand  that  his  recovery  will  be 
slower  and  that  a  permanent  induration  of  the  globus 
minor  and  obstruction  of  the  vas  deferens  will  probably 
follow.  The  scrotum  over  the  affected  testicles  may  be 
smeared  lightly  with  an  opium-and-belladonna  ointment, 
covered  with  a  "  dry  poultice,"  and  the  whole  supported 
and  made  as  immovable  as  possible  with  the  wide  band- 
age already  recommended,  or — what  is  often  more  effec- 
tive when  the  patient  is  on  his  feet — with  the  Horand- 
Langlebert  suspensory,  which  may  be  obtained  from  the 
makers  of  surgical  appliances.  By  avoiding  sudden  and 
rapid  movements  the  patient  is  often  enabled  to  move 
about  with  comparatively  little  discomfort.  For  these 
cases  Dr.  W.  S.  Halstead  and  others  touch  the  surface  of 
the  scrotum  lightly  in  several  places  with  the  point  of 
the  cautery  at  a  white  heat ;  iodoform  ointment  is  then 
applied,  and  the  testicle  is  properly  supported.  This 
method  frequently  relieves  the  pain  and  allows  the 
patient  to  remain  up  and  to  move  about.  Tincture  of 
iodine  and  strong  solutions  of  nitrate  of  silver  have  been 
used  to  paint  the  scrotum  and  to  produce  counter-irrita- 
tion, but  they  usually  fail  to  do  much  good,  and  they 
often  cause  a  severe  dermatitis  of  the  scrotum. 

When  possible,  every  patient  with  epididymitis  should 
be  kept  on  his  back  until  the  pain  has  subsided  and  the 
swelling  has  been  reduced  somewhat  (from  three  to 
eight  days) ;  but  if  he  is  then  unwilling  to  spend  more 
time  in  bed,  he  may  be  allowed  to  rise  and  go  about 
if  his  testicle  is  first  properly  strapped.  To  determine 
if  a  testicle  is  ready  for  strapping,  the  organ  is  taken  in 
the   hand   and  gently  manipulated  for  several  minutes, 


EPIDID  YMITIS.  45  3 

gradually  bringing  the  testicle  to  the  bottom  of  the 
scrotum,  which  is  encircled,  just  above  the  testicle,  by 
the  thumb  and  forefinger,  forming  a  ring  which  gentle 
pressure  is  making  gradually  narrower.  These  manipu- 
lations will  probably  cause  some  pain  in  the  testicle  or 
in  the  groin,  but  this  pain  will  usually  disappear  without 
relaxing  the  pressure  if  the  operating  hand  be  held  mo- 
tionless for  a  few  seconds.  If  the  pain  is  but  slight 
when  the  ring  formed  by  the  thumb  and  the  finger  is  too 
small  for  the  testicle  to  escape  through  it  upward,  and 
the  testicle  is  thus  secured  in  a  smooth,  tense,  and  shin- 
ing pouch  of  the  scrotum,  strapping  is  proper. 

For  strapping  the  testicle  rubber  adhesive  plaster  or 
lead-plaster  may  be  used,  in  strips  half  an  inch  wide. 
The  hairs  should  be  cut  from  the  scrotum,  to  prevent 
their  being  pulled  by  the  plaster  on  its  removal.  The 
most  difficult  and  most  important  part  of  the  whole  pro- 
cedure lies  in  applying  the  first  strip  of  plaster,  which 
must  be  made  to  take  the  place  of  the  thumb  and  the 
finger  in  forming  a  ring  to  hold  the  testicle  in  the  posi- 
tion described  above.  The  strip  should  be  half  an  inch 
wide  and  three  or  four  inches  longer  than  necessary  to 
encircle  the  testicle.  To  its  under  (adhesive)  surface  is 
fastened  a  cotton  bandage  an  inch  and  a  half  wide  and 
enough  shorter  than  the  plaster  to  leave  one  end  of  the 
latter  uncovered  for  two  or  three  inches.  The  bandage 
is  used  to  prevent  the  edge  of  the  plaster  from  cutting 
the  scrotum. 

The  patient  stands,  or  sits  on  the  edge  of  a  chair, 
in  front  of  the  operator,  who  has  taken  the  precaution 
to  have  his  strips  of  plaster,  bandage,  scissors,  etc. 
ready  and  within  easy  reach.  When  the  left  hand  has 
once  more  secured  the  testicle  in  the  desired  posi- 
tion, the  pressure  may  be  relaxed  without  changing  the 
position  of  the  hand,  and  the  prepared  adhesive  strip  is 
placed  around  the  scrotum  in  the  position  just  vacated 
by  the  thumb  and  the  finger.  The  thumb  and  the  finger 
again  encircle  the  scrotum  above  and   outside  of  the 


454      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

adhesive  strip,  holding  the  end  covered  by  the  bandage 
in  position  and  forcing  the  testicle  down,  while  the  right 
hand  brings  around  the  free  end  of  the  plaster  and  fastens 
it  to  the  back  of  the  fixed  end.  If  properly  done,  the 
testicle  is  secured  in  a  smooth,  tense,  purplish  pouch 
of  the  scrotum,  the  adhesive  strip  forming  a  ring  too 
small  to  allow  the  escape  upward  of  the  testicle.  After 
waiting  two  or  three  minutes  to  allow  the  pain  to  sub- 
side (as  it  will  do  if  the  plaster  be  not  drawn  too  tight), 
the  operator  applies  several  more  circular  strips  parallel 
with  the  first,  each  strip  overlapping  the  one  last  applied 
by  about  half  its  width.  When  strips  applied  in  this 
direction  will  no  longer  fit  the  surface,  others  may  be 
fastened  to  the  first  strip  on  one  side,  carried  over  the 
testicle,  and  fastened  to  the  first  strip  on  the  opposite 
side,  until  the  entire  surface  below  the  ring  is  firmly  and 
completely  covered.  A  long  circular  strip  should  finally 
be  applied  to  cover  and  hold  the  ends  of  the  strips  last 
applied.  When  finished  the  covering  should  exert  even 
pressure  upon  the  entire  surface,  thus  encouraging  ab- 
sorption and  preventing  the  possibility  of  a  return  of  the 
swelling. 

It  is  always  best  to  have  the  patient  rest  quietly 
for  half  an  hour  or  more  after  strapping  the  testicle, 
until  the  pain  caused  by  the  manipulations  has  dis- 
appeared, when  he  can  support  the  scrotum  with  a 
suspensory  bandage  (made  to  fit  by  lining  it  with  cotton), 
and  go  about  his  business  in  comfort  and  without  fear 
of  a  relapse.  If  the  dressing  remains  painful  after  an 
hour,  or  if  it  becomes  so  at  any  time,  it  should  be  re- 
moved either  by  cutting  the  separate  strips  or  by  im- 
mersing the  whole  in  hot  water  until  it  can  be  slipped 
off.  Pain  will  follow  strapping  if  the  testicle  is  not  ready 
for  it,  if  the  ring  formed  by  the  first  strap  be  too  tight, 
or,  as  frequently  happens,  if  the  ring  be  so  large  that  the 
testicle  is  forced  partially  into  it  by  the  other  straps. 
At  the  end  of  from  twenty-four  to  forty-eight  hours  the 
swelling  will  have  been  so  reduced  in  size  that  the  dress- 


E PID ID  ymitis.  45  5 

ing  no  longer  exerts  pressure  upon  the  testicle,  which 
sometimes  escapes  through  the  ring,  and  a  new  strap- 
ping is  necessary.  The  procedure  is  repeated  four  or 
five  times  until  all  that  remains  of  the  swelling  is  the 
indurated  globus  minor. 

For  several  weeks,  until  all  swelling  is  reduced  to  a 
painless  induration,  a  well-fitting  suspensory  should  be 
worn.  This  is  done  to  prevent  a  relapse  and  to  hasten 
absorption,  a  process  that  may  be  aided  by  daily  inunc- 
tion over  the  nodule  with  oleate  of  mercury  (2  to  10 
per  cent.),  and  by  lining  the  suspensory  with  oiled  silk 
and  a  thin  layer  of  wool  to  form  a  light  "  dry  poultice." 
Too  early  suspension  of  treatment,  and  especially  of 
support  for  the  parts,  may  lead  to  chronic  inflammation 
of  the  epididymis  and  the  cord.  After  all  acute  symp- 
toms have  disappeared,  the  proper  use  of  electricity  may 
hasten  absorption  of  the  remaining  deposit. 

The  treatment  of  subacute  and  chronic  epididymitis 
is  that  of  the  declining  stages  of  the  acute  process.  In 
addition,  all  predisposing  and  exciting  causes  should  be 
removed.  In  stubborn  cases  resolution  may  sometimes 
be  hastened  by  treatment  with  mercury  and  iodide  given 
internally,  even  when  there  is  no  possible  syphilitic 
element  in  the  case. 

Prognosis. — Epididymitis  almost  always  terminates 
in  resolution ;  suppuration  is  very  rare  except  in  the 
uncommon  chronic  cases.  Absorption  of  inflammatory 
products  is  rapid  at  first,  and  at  the  end  of  a  few  weeks 
of  good  treatment  all  pain  and  tenderness  have  dis- 
appeared, and  there  remains  only  some  swelling  and 
induration  of  the  globus  minor  or  major.  This  remain- 
ing induration  may  require  months  or  years  for  its  final 
absorption,  and  frequently  persists  permanently  in  the 
form  of  a  hard  nodule  found  to  be  composed  of  inflam- 
matory deposits  in  and  surrounding  the  seminal  canals, 
which  are  thus  completely  occluded. 

Permanent  induration  is  most  common  in  the  globus 
minor,  and,  as  this    body  is  composed  of    the   convo- 


456      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

lutions  of  a  single  tube,  the  blocking  of  any  portion 
of  it  prevents  the  passage  of  the  semen  from  the 
testicle  proper  to  the  vas  deferens.  Even  when  all 
apparent  induration  has  disappeared,  and  this  portion 
of  the  epididymis  again  feels  normal  to  the  palpating 
finger,  the  canal  may  be  filled  and  obstructed  at  some 
point.  Complete  absorption  of  the  deposit  and  re- 
opening of  the  canal  in  the  globus  minor  can  be  ex- 
pected in  but  a  small  minority  of  cases.  In  the  globus 
major  complete  absorption  is  more  common,  and  even 
if  it  does  not  occur,  some  of  the  tubules  may  escape 
obstruction.  It  follows  that  the  large  majority  of  men 
who  have  had  epididymitis  on  both  sides  are  sterile. 
The  cause  of  their  sterility  lies  solely  in  mechanical 
obstruction  to  the  passage  of  semen,  since  the  testicle 
does  not  atrophy  nor  is  the  man  impotent.  He  retains 
his  sexual  appetite  and  power,  and  ejaculates  a  fluid 
resembling  semen  except  that  it  contains  no  sper- 
matozoa. 

In  a  tubercular  or  syphilitic  patient  epididymitis  may 
be  followed  by  the  appearance  of  the  constitutional 
disease  in  the  epididymis. 

Subacute  and  chronic  cases  of  epididymitis  terminate 
favorably  when  proper  treatment  is  continued  for  a 
sufficient  period. 

PROSTATITIS. 

I.  Acute  Prostatitis. — When  gonorrhceal  inflamma- 
tion reaches  the  posterior  urethra,  it  frequently  includes 
the  superficial  glands  and  follicles  of  the  prostate,  and 
it  may  readily  involve  the  entire  structure  of  the  organ. 
Prostatitis  commonly  appears  after  the  third  week  of 
gonorrhoea,  its  symptoms  following  or  appearing  simul- 
taneously with,  and  possibly  obscuring,  those  of  pos- 
terior urethritis.  It  occurs  also  with  chronic  urethritis 
and  with  stricture.  The  exciting  causes  are  practically 
those  of  posterior  urethritis  and  epididymitis — namely, 
coitus;  prolonged  or  intense  sexual  excitement;  violent 


PROSTATITIS.  457 

exercise ;  excessive  use  of  alcohol,  tobacco,  or  highly 
seasoned  foods ;  exposure  to  cold ;  and  mechanical  or 
chemical  injury  due  to  the  use  of  instruments  or  injec- 
tions, or  possibly  to  a  concentrated  and  irritating  urine. 
It  is  possible  that  some  of  these  causes  may  produce 
prostatitis  independently  of  gonorrhoea. 

Symptoms. — Follicular  Prostatitis. — If  the  inflamma- 
tion be  limited  to  a  few  follicles,  the  symptoms  will  be 
those  of  posterior  urethritis,  with  the  probable  addition 
of  sharp,  sticking  pains  most  noticeable  at  the  close  of 
urination.  The  finger  in  the  rectum  may  find  one  or 
more  firm,  tender  nodules  in  the  substance  of  the  pros- 
tate, which  is  possibly  somewhat  congested  and  slightly 
swollen,  but  not  inflamed  or  very  sensitive.  These  in- 
flammations may  undergo  resolution,  the  symptoms 
disappearing  with  those  of  the  posterior  urethritis ;  or 
they  may  extend  to  the  rest  of  the  prostate ;  or,  finally, 
they  may  linger  indefinitely  in  the  form  of  a  chronic 
folliculitis. 

Diffuse  or  Parenchymatous  Prostatitis. — In  this  form  of 
prostatitis  the  symptoms  are  much  more  pronounced 
and  characteristic.  The  prostate  swells  rapidly,  notwith- 
standing the  fact  that  it  is  surrounded  by  a  firm,  fibrous 
capsule,  and  the  resulting  pressure  to  which  the  inflamed 
organ  is  subjected  produces  violent  pains  and  interferes 
greatly  with  the  urinary  and  sexual  functions.  There  is 
frequency  of  urination,  tenesmus,  and  the  patient  ex- 
periences a  feeling  of  fulness  and  warmth  in  the  rectum, 
producing  an  almost  constant  desire  to  empty  the  bowel, 
and  leading  him  to  make  frequent  and  often  violent 
efforts  to  expel  what  he  thinks  is  a  mass  of  faeces,  but 
which  is  really  the  swollen  prostate  protruding  into  the 
rectum.  Defecation  is  painful,  and  there  may  be  tenes- 
mus of  the  bowel.  Urination  is  also  painful,  especially 
at  the  close  of  the  act,  when  the  patient  may  experience 
violent  sharp  pains  due  to  the  squeezing  of  the  tender 
prostate  by  the  sphincter  vesicas  muscle,  and  the  last 
drops  of  urine  may  be  mixed  with  blood.     The  stream 


458      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

of  urine  is  often  reduced  in  size,  and  the  pressure  upon 
the  prostatic  urethra  may  be  sufficient  to  cause  complete 
retention. 

In  addition  to  the  subjective  sensations  already- 
described,  the  patient  complains  of  fulness,  pressure, 
weight,  and  pain  in  the  perineum,  which  may  be  hot 
and  so  tender  that  the  sitting  posture  or  crossing  of 
the  legs  cannot  be  endured.  The  pain  is  variously 
described  by  patients  as  sharp,  lancinating,  shooting, 
boring,  or  throbbing  in  character,  and  radiates  from  the 
prostate  and  perineum  to  the  urethra,  testicles,  thighs, 
and  back.  With  the  finger  in  the  rectum  the  prostate  is 
outlined  as  a  firm,  hot,  pulsating,  more  or  less  irregular 
tumor,  which  is  exceedingly  sensitive  to  pressure,  and 
which  in  severe  cases  may  become  almost  as  large  as  a 
man's  fist,  and  may  entirely  occlude  the  rectum. 

The  disease  is  usually  accompanied  from  the  begin- 
ning with  some  fever  and  constitutional  disturbance,  and 
by  diminution  or  cessation  of  the  urethral  discharge 
during  the  swelling  of  the  prostate.  A  marked  feature 
of  prostatitis,  and  one  for  which  the  inexperienced  prac- 
titioner is  rarely  prepared,  is  the  mental  attitude  of  the 
patient,  whose  restlessness,  fears,  and  anxiety  are  out  of 
all  proportion  to  the  severity  of  the  process.  As  Keyes 
well  says :  "  The  patient  is  irritable,  despondent,  and 
suspicious,  often,  in  fact,  wild  to  an  extent  amounting  to 
mild  acute  mania."  He  is  inclined  to  be  dissatisfied  with 
all  that  is  done  for  him — in  short,  is  usually  a  very  un- 
satisfactory patient  to  treat  during  the  acute  process, 
unless  he  can  have  a  constant  attendant  to  watch  over 
him  and  properly  to  carry  out  the  physician's  orders. 

The  course  of  the  disease,  when  it  ends,  as  it  com- 
monly does,  in  resolution,  is  short ;  the  symptoms 
appear  more  or  less  suddenly,  rapidly  increase  to  the 
highest  point,  and  almost  as  rapidly  subside,  so  that  the 
acute  stage  varies  in  duration  from  four  to  ten  days,  and 
final  recovery  follows  in  another  week  or  two.     As  the 


PR  OSTA  TITIS.  459 

symptoms  subside  and  the  urethral  discharge  reappears, 
the  latter  may  at  times  be  changed  in  character  by  ad- 
mixture with  a  thick,  viscid  mucus  and  pus  from  the 
prostatic  follicles  ;  and  if  the  seminal  vesicles  have  been 
involved,  the  discharge  may  contain  a  few  spermatozoa. 

Instead  of  undergoing  resolution,  the  inflammation 
may  go  on  to  suppuration  involving  portions  or  all  of 
the  prostate.  In  some  instances  a  number  of  miliary 
abscesses  form.  The  formation  of  pus  is  usually  an- 
nounced by  a  decided  chill  and  a  marked  increase  in 
temperature,  and  the  constitutional  disturbance  may  be 
considerable.  The  feeling  of  tension  in  the  perineum  is 
usually  diminished,  and  the  pains  may  lose  their  intense, 
boring  character  and  become  cutting  and  throbbing. 
Retention  of  urine  commonly  results.  Fluctuation  can 
sometimes  be  felt  through  the  rectum.  If  untreated, 
these  abscesses  rupture  into  the  urethra,  the  rectum,  or 
the  perineum,  the  order  of  frequency  being  that  given. 
Exceptionally,  they  extend  beyond  the  limits  of  the 
prostate,  burrow  extensively  between  the  layers  of  the 
pelvic  fascia,  and  open  into  the  ischio-rectal  fossa,  the 
inguinal  region,  or  even  into  the  peritoneum,  and  may 
cause  death  from  sepsis  or  from  peritonitis.  Occasion- 
ally an  abscess  will  discharge  into  both  urethra  and 
rectum  or  into  the  urethra  and  some  other  region,  as  the 
perineum,  and  result  in  urinary  fistula.  Rupture  of  the 
abscess  brings  immediate  relief  from  pain ;  if  the  abscess 
be  a  small  one,  opening  into  the  urethra,  it  will  usually 
fill  with  granulations  and  slowly  heal.  An  opening  into 
the  rectum  is  unfavorable,  since  the  cavity  is  more  liable 
to  infection  and  can  be  kept  clean  only  with  great  difficulty. 

Occasionally  during  gonorrhoea,  stricture,  or  conse- 
quent inflammation  of  the  seminal  vesicles  or  of  the  vas 
deferens,  suppuration  may  occur  in  the  tissues  surround- 
ing the  prostate  (periprostatic  abscess).  As  these  ab- 
scesses are  situated  in  looser  tissues,  their  symptoms  are 
less  acute  than  in  prostatic  abscess,  and  the  finger  in  the 
rectum  locates  them  outside  the  capsule  of  the  prostate ; 


460      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

but  in  other  respects  their  course  is  practically  that  of 
prostatic  abscess. 

Treatment. — First  and  most  important  is  rest,  which 
in  severe  cases  should  be  made  as  nearly  absolute  as 
possible.  The  patient  must  resist  his  constant  desire  to 
urinate  and  to  empty  the  bowel,  and  must  refrain  from 
straining  at  stool  or  in  urinating  if  he  would  avoid  the 
dangers  of  prostatic  abscess.  Rest  in  bed  with  the  hips 
elevated ;  the  application  of  fomentations  (see  treat- 
ment of  epididymitis)  large  enough  to  cover  anus,  peri- 
neum, and  hypogastrium ;  hot  sitz-baths,  hot  enemata 
given  two  or  three  times  daily,  or  frequent  and  prolonged 
irrigation  of  the  rectum  with  hot  water,  by  means  of  a 
catheter  or  rectal  irrigator;  the  internal  administration 
of  alkalies  and  bland  fluids  in  quantities  sufficient 
to  keep  the  urine  unirritating  (see  hygiene  of  gon- 
orrhoea) ;  and  the  use  of  anodynes  to  control  pain 
and  tenesmus,  constitute  the  best  treatment  of  most 
cases;  if  begun  early  and  faithfully  continued,  this 
treatment  will  usually  render  the  attack  a  mild  one. 

Anodynes  are  best  given  in  the  form  of  opium-and- 
belladonna  suppositories,  and  in  quantities  sufficient  to 
allay  the  irritation  of  the  bladder  and  rectum  and  to 
keep  the  patient  quiet.  As  in  posterior  urethritis,  hyos- 
cyamus  given  internally  is  often  valuable  in  relieving 
tenesmus.  Mustard  or  turpentine  may  be  added  to  the 
fomentations  to  produce  counter-irritation,  and  in  severe 
cases  ten  or  fifteen  leeches  may  be  applied  to  the  perineum. 

The  patient  should  be  put  on  a  light  diet,  and  his 
bowels  should  be  moved  with  enemata,  cathartics  being 
generally  contraindicated,  though  a  brisk  calomel  purge 
at  the  beginning  of  treatment,  or  yV  to  \  grain  of 
calomel  given  every  hour  until  the  bowels  move,  is  often 
productive  of  excellent  results.  Sometimes  it  is  neces- 
sary to  give  bromides  and  chloral  to  quiet  the  mental 
excitement,  produce  sleep,  and  allow  the  patient  rest, 
but  usually  they  are  not  as  beneficial  as  the  presence  of 
a  well-trained  attendant  who  will  properly  execute  the 


PR  OS  TA  TITIS.  46 1 

physician's  orders,  keep  the  patient  under  control,  and 
add  to  his  comfort  and  rest  by  daily  sponging  or  skilful 
rubbing  of  the  body,  etc.  All  treatment  of  gonorrhoea 
should  be  suspended  with  the  first  symptoms  of  prosta- 
titis, and  the  prostate  should  not  be  teased  by  too 
frequent  examinations  through  the  rectum.  Retention 
of  urine  should  be  relieved  by  the  use  of  the  hot  bath 
when  possible,  but  if  this  fails  a  small  soft  catheter  may 
be  used  gently  after  first  injecting  the  urethra  full  of 
warm  oil,  as  directed  for  retention  in  acute  gonorrhoea. 

Finger  and  other  German  surgeons  highly  recommend 
the  use  of  cold,  instead  of  hot,  local  applications.  If  be- 
gun early  enough,  the  course  of  the  disease  may  be  cut 
short  by  using  the  cold  rectal  sound.  This  instrument  is 
a  hollow  sound  with  two  longitudinal  compartments  con- 
nected at  the  end,  through  which  water  may  flow  in  a 
constant  stream.  The  sound  is  well  oiled,  is  gently  in- 
troduced into  the  rectum  until  it  comes  in  contact  with 
the  prostate,  and  cold  water — even  ice  cold — is  allowed 
to  flow  through  it  for  half  an  hour  or  an  hour,  once,  twice, 
or  three  times  a  day.  The  same  sound  may  be  used 
for  the  application  of  heat,  which  is  more  acceptable  and 
more  beneficial  in  most  cases.  The  hot  applications 
may  be  continued  for  longer  periods  than  the  cold. 

When  an  abscess  forms  the  treatment  is  surgical,  a  peri- 
neal opening  being  always  the  most  desirable.  If  fluctua- 
tion can  be  felt. through  the  rectum,  the  abscess  may  be 
aspirated  or  be  punctured  with  a  trocar,  but  an  opening 
into  the  rectum  is  to  be  avoided  when  possible,  since 
some  of  the  contents  of  the  intestine  are  certain  to  get 
into  the  cavity  and  to  interfere  with  healing.  When  a 
small  abscess  bursts  into  the  urethra,  boric  acid,  uro- 
tropin,  or  salol  and  bland  fluids  internally,  to  keep  the 
urine  antiseptic  and  unirritating,  constitute  the  only  treat- 
ment required  unless  further  symptoms  appear.  Ab- 
scesses which  open  in  other  directions  should  be  treated 
on  surgical  principles — with  irrigations  and  astringent 
injections. 


462      SYPHILIS  AND    THE  VENEREAL  DLSEASES. 

II.  Chronic  Prostatitis. — Chronic  prostatitis  may 
follow  an  acute  attack,  may  occur  in  subacute  form  dur- 
ing chronic  urethritis  or  with  stricture,  or  may  arise  from 
any  cause  that  produces  prolonged  congestion  or  irrita- 
tion of  the  prostatic  urethra.  The  inflammation  may 
be  limited  to  a  few  of  the  superficial  follicles  and  glands 
opening  into  the  urethra,  and  be  very  mild,  simply 
catarrhal  in  type,  or  it  may  involve  the  entire  glandu- 
lar structures,  together  with  more  or  less,  or  even  all,  of 
the  parenchyma  of  the  prostate. 

Symptoms. — In  the  mild  forms,  commonly  known  as 
clironic  follicular  prostatitis,  or  prostatorrhosa,  in  which 
the  superficial  glands  and  follicles  are  alone  affected,  the 
chief  symptom  is  the  discharge  from  the  meatus  of  a 
thick,  sticky,  bluish  or  milky-looking  fluid  composed  of 
a  glairy  mucus,  a  few  pus  cells,  and  short  comma-like 
shreds  from  the  prostatic  follicles.  This  discharge  is 
intermittent,  appearing  most  frequently  at  the  close  of 
urination,  at  stool,  or  after  an  erection,  or  it  can  be 
pressed  out  of  the  prostate  by  the  finger  in  the  rectum. 
If  the  urine  be  examined  by  the  three-glass  test  (see 
diagnosis  of  chronic  gonorrhoea),  most  of  the  discharge 
will  be  found  in  the  third  glass,  though  a  small  portion 
is  usually  washed  into  the  first.  The  second  glass  con- 
tains clear  urine.  The  contents  of  the  first  glass  may  be 
modified  by  secretion  from  the  anterior  urethra,  as 
chronic  prostatitis  is  frequently  accompanied  by  chronic 
anterior  urethritis,  especially  of  the  bulbar  portion. 
Under  the  microscope  the  discharge  is  seen  to  con- 
tain pus-cells,  polygonal  and  cylindrical  epithelium, 
amorphous  and  fatty  matter,  and  the  needle-shaped 
and  whetstone-shaped  "  sperma-crystals."  If,  by  press- 
ure on  the  prostate,  a  drop  of  the  prostatic  secretion 
be  obtained  free  from  urine,  and  to  it  be  added  a  drop  of 
a  1  per  cent,  solution  of  ammonia  phosphate,  and  the 
mixture  be  allowed  to  dry  slowly  under  a  cover-glass, 
these  crystals  can  easily  be  demonstrated.  Spermatozoa 
are  not  present  unless  the  seminal  vesicles  are  inflamed. 


PR  OSTA  TITIS.  463 

The  patient  usually  describes  these  discharges  as  sem- 
inal losses,  and  believes  himself  the  subject  of  sperma- 
torrhoea. In  consequence  he  is  often  despondent  and 
hypochondriacal  and  inclined  to  exaggerate  greatly  the 
severity  of  his  subjective  discomforts,  which  may  be 
confined  to  vague  and  uneasy  sensations  in  the  peri- 
neum, with  slightly  increased  frequency  in  urination 
and  some  irritability  of  the  sexual  organs.  In  some 
cases  and  especially  in  neurotic  individuals,  the  symp- 
toms are  more  pronounced,  corresponding  with  those 
usually  seen  in  the  severe  types  of  the  disease. 

Extension  of  the  inflammation  to  the  deeper  glands 
and  parenchyma  of  the  prostate  produces  a  graver  form 
of  the  disease,  known  as  chronic  parenchymatous  prosta- 
titis. The  symptoms  of  this  form  vary  greatly,  depend- 
ing upon  the  extent  and  severity  of  the  process.  In 
addition  to  the  discharge,  there  may  be  tenesmus  and 
increased  frequency  of  urination,  with  pain  and  possibly 
slight  hemorrhage  at  the  close  of  the  act.  There  are 
burning,  heavy,  uneasy  sensations  in  the  perineal  region, 
with  pains  radiating  to  the  urethra,  testicles,  groins, 
thighs,  and  back.  These  sensations  are  increased  on 
urination,  defecation,  or  sexual  intercourse,  and  the  pains 
may  even  be  neuralgic  in  character,  being  often  described 
as  neuralgia  of  the  urethra,  testicle,  and  bladder.  In 
severe  cases  the  pain  is  greatly  increased  by  jolting, 
crossing  the  thighs,  walking,  or  even  by  the  sitting 
posture.  There  are  often  teasing,  tickling  sensations  of 
the  prepuce  and  the  meatus,  and  not  infrequently  the 
patient  complains  of  pain  about  an  inch  back  of  the 
meatus  on  the  under  side  of  the  urethra. 

The  deep  urethra  and  the  vesical  neck  are  often  ex- 
ceedingly sensitive,  and  spasmodic  contractions  of  the 
sphincter  muscles  may  cause  a  sudden  stopping  of  the 
stream  near  the  close  of  urination.  There  is  usually 
irritation  of  the  sexual  organs,  with  frequent  emissions, 
which  may  be  bloody ;  in  severe  cases  emissions  and 
prolonged,    often    painful,    erections    are    common,    yet 


464      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

sexual  desire  and  gratification  may  be  diminished  or 
entirely  absent.  Spermatozoa  are  present  in  the  semen, 
but,  owing  to  the  absence  of  normal  prostatic  secretions, 
they  are  inactive,  and  sterility  results. 

The  patient  is  usually  mentally  depressed,  irritable, 
and  melancholy.  Other  constitutional  disturbances  are 
slight  at  first,  and  may  remain  so  for  months,  notwith- 
standing severe  local  symptoms  and  a  hypochondriacal 
state  of  mind  that  is  most  deplorable;  but  unless  the 
local  disorder  is  relieved  and  the  mental  condition  is 
improved,  there  follows,  sooner  or  later,  a  long  series  of 
morbid  nervous  phenomena  constituting  the  unfortunate 
state  generally  known  as  "  neurasthenia."  These  symp- 
toms are  vague,  varied,  and  numerous.  At  first  they 
refer  chiefly  to  the  genito-urinary  system,  but  later  they 
may  apply  to  any  or  every  organ  in  the  body.  Among 
the  earliest  and  most  common  complaints  of  these  patients, 
besides  those  already  given,  may  be  mentioned  constant 
weariness  and  weakness,  aching  pain  in  the  back  and 
legs,  a  heavy,  dull  feeling  in  the  head,  headache,  loss 
of  memory  and  inability  to  concentrate  the  mind  upon 
work,  sleeplessness,  hot  and  cold  flushes  or  numbness 
with  tingling  sensations,  and  any  or  all  of  the  symp- 
toms that  may  result  from  impaired  functional  activity 
of  the  various  organs  of  the  body.  The  patient  may  com- 
plain of  many  of  these  symptoms  while  still  appearing 
well  nourished,  but  in  most  cases  that  fail  to  improve,  mal- 
nutrition, loss  of  weight,  and  impairment  of  the  general 
health  sooner  or  later  result.  The  skill,  patience,  and  tact 
of  the  physician  are  often  taxed  to  the  utmost  in  his  efforts 
to  determine  if  it  be  the  local  disease  or  the  hypochon- 
driasis that  is  chiefly  responsible  for  the  neurasthenic 
symptoms. 

Dr.  W.  T.  Belfield  has  called  attention  to  the  fact  that 
chronic  inflammation  of  the  prostate  is  usually  not 
limited  to  that  organ,  but  invades  portions  or  all  of  the 
seminal  vesicle,  vas  deferens,  and  epididymis,  together 
with  the  surrounding  connective  tissue ;  he  states  that 


PR  OSTA  TITIS.  465 

chronic  suppuration  is  a  frequent  feature  of  such  inflam- 
mation, the  small  abscesses  being  usually  unrecognized 
until  they  rupture  into  the  urethra,  rectum,  or  pelvic 
tissues,  or  until  revealed  by  autopsy.  The  extent  and 
nature  of  this  more  diffuse  inflammation  may  be  respon- 
sible for  some  of  the  varied  symptoms  usually  ascribed 
solely  to  chronic  prostatitis. 

Treatment. — In  the  majority  of  cases  the  treatment 
is  largely  that  of  chronic  posterior  urethritis,  and  the 
reader  is  referred  to  that  subject  for  the  detailed  descrip- 
tion of  some  of  the  methods  here  suggested.  The  most 
generally  successful  treatment  is  found  in  deep  irrigations, 
combined  with  general  massage  of  the  prostate  by  the 
finger  in  the  rectum. 

Massage  should  never  be  undertaken  if  acute  symp- 
toms are  present,  or  if  the  operation  is  very  painful  or 
proves  irritating.  The  object  of  the  procedure  is  to 
gently  empty  the  deeper  seated  follicles,  so  far  as 
possible,  of  accumulated  secretion.  This  massage  of 
the  prostate  should  be  done  with  great  gentleness,  and 
the  effect  carefully  noted  in  each  case  before  employing 
firmer  pressure.  This  treatment  should  be  given  at  first 
not  oftener  than  once  in  four  or  five  days;  if  no  irritation 
follows,  it  may  be  given  every  second  or  third  day,  or, 
exceptionally,  every  day. 

For  the  milder  cases  the  use  of  the  cold-steel  sound, 
as  recommended  for  chronic  urethritis,  is  a  valuable 
remedy.  Deep  injections  of  nitrate  of  silver  or  of  lanolin 
ointments  may  be  used  in  connection  with  the  sound. 
Good  results  often  follow  the  use  of  the  psychrophore, 
as  in  chronic  urethritis,  or  the  frequent  and  prolonged 
application  of  hot  or  cold  by  use  of  the  metal  hollow 
sound,  as  in  the  acute  form  of  the  disease.  Correct 
hygiene  and  the  general  health  of  the  patient  are 
of  greatest  importance,  and  sometimes  the  best  re- 
sults are  obtained  from  a  trip  to  the  sea-shore  or  to 
the  mountains  combined  with  other  measures  adapted 
to    the    needs    of    the    individual.     The    mental     state 

30 


466      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

frequently  calls  for  as  much  treatment  as  does  the 
local  condition,  since  it  may  be  impossible  to  obtain  rest 
and  proper  hygiene  for  the  affected  parts  until  the  fears 
and  anxieties  of  the  patient  have  in  some  measure  been 
removed.  The  cessation  of  local  treatment  to  allow 
the  organs  a  period  of  rest  is  often  necessary ;  and  it 
must  not  be  forgotten  that  too  continuous  or  too  ener- 
getic measures  may  aggravate  the  existing  disorder  and 
produce  an  acute  type  of  the  disease. 

In  the  more  severe  forms  blistering  the  perineum  is 
often  an  aid  to  effective  treatment.  Mustard,  turpentine, 
or  cantharides  may  be  used,  but  cantharidal  collodion  is 
perhaps  the  most  convenient.  The  perineum  is  shaved, 
the  scrotum  and  the  margin  of  the  anus  are  protected 
by  a  simple  thick  ointment,  and  the  collodion  is  applied 
to  one-half  of  the  perineum.  The  scrotum  is  then  pro- 
tected and  kept  out  of  the  way  by  the  use  of  a  suspen- 
sory, and  the  perineum  is  covered  with  a  light  dressing 
of  absorbent  cotton.  When  the  resulting  blister  has 
healed  and  the  soreness  diminishes,  the  other  half  of 
the  perineum  may  be  treated  in  the  same  way,  and  the 
process  may  be  repeated  often  enough  to  keep  one  side 
or  the  other  of  the  perineal  surface  constantly  irritated 
for  a  number  of  weeks,  until  the  symptoms  of  prostatitis 
have  been  largely  relieved.  During  this  treatment  the 
patient  must  be  kept  quiet  and  in  bed  as  much  of  the 
time  as  possible,  while  the  state  of  his  general  health 
should  be  carefully  studied  and  improved  in  every  way 
possible.  Tonics,  mild  laxatives  or  enemata,  alkalies, 
and  diluent  drinks  are  necessary  in  most  cases. 

Prognosis. — Acute  symptoms  disappear  in  a  short 
time  under  good  management,  but  great  sensitiveness> 
congestion,  and  other  relics  persist  for  months  and  may 
terminate  in  one  of  the  chronic  forms  of  the  disease. 
Prostatic  or  periprostatic  abscess  is  occasionally  followed 
by  urinary  fistulae,  which  may  heal  only  after  repeated 
operations.  The  chronic  forms  of  the  disease  are 
usually  very  stubborn,  but  with  time,  patience,  hygiene, 


VESICULITIS.  467 

and  good  treatment  they  are  greatly  relieved  and  usually 
recover.  The  general  health  commonly  remains  good 
unless  disturbed  by  loss  of  rest  and  long-continued  men- 
tal depression.     Suppuration  very  rarely  results  fatally. 

VESICULITIS. 

Inflammation  of  the  seminal  vesicles  may  occur  dur- 
ing gonorrhoea,  as  the  result  of  a  direct  extension  of  the 
process  from  the  posterior  urethra.  The  exciting  causes 
are  those  of  posterior  urethritis,  prostatitis,  and  epididy- 
mitis, viz. :  coitus,  masturbation,  sexual  excitement,  alco- 
hol, exercise,  or  anything  that  produces  congestion  of 
this  region.  Acute  vesiculitis,  however,  is  less  common 
than  the  chronic  form,  which  may  follow  the  former,  but 
which  more  frequently  appears  in  subacute  form  during 
chronic  urethritis.  It  may  also  be  due  to  stricture  or 
to  prolonged  congestion,  irritation,  and  inflammation  of 
the  posterior  urethra  from  any  cause,  and  is  commonly 
associated  with  prostatitis  and  posterior  urethritis.  The 
persistence  of  the  latter  disease  is  undoubtedly  often 
due  to  an  unrecognized  acute  or  chronic  vesiculitis.1 

Symptoms. — In  the  acute  form  the  symptoms  are 
practically  those  found  in  acute  posterior  urethritis  and 
acute  prostatitis,  with  which  disorders  vesiculitis  is 
often  associated.  The  differential  diagnosis  is  fre- 
quently difficult.  The  pain  is,  however,  often  more 
localized  in  the  suprapubic  region,  in  the  sacrum,  or  in 
the  bladder,  and  in  addition  to  tenesmus,  frequent  mictu- 
rition, painful  and  disagreeable  sensations  in  the  peri- 
neum, etc.,  there  are  usually  characteristic  disturbances 
of  the  sexual  functions.  Sexual  desire  is  stimulated 
and  may  be  almost  constant,  though  during  the  febrile 
stage  it  may  be  absent.  There  are  frequent  emissions 
occurring  on  the  slightest  provocation,  and  prolonged, 
sometimes  painful,  erections.  Ejaculation  is  usually 
precipitate,    unaccompanied    by  pleasure    or    relief,   and 

1  For  a  complete  presentation  of  this  subject  see  Disorders  of  the  Male 
Sexual  Organs,  by  Eugene  Fuller. 


468      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

extremely  painful.  The  seminal  discharge  contains  pus, 
dead  spermatozoa,  and  frequently  blood. 

In  subacute  and  chronic  vesiculitis  the  above  symp- 
toms may  be  present  in  lesser  degree,  or  there  may  be 
great  diminution  of  sexual  desire,  with,  however,  fre- 
quent and  more  or  less  painful  emissions.  The  dis- 
charge contains  less  pus  and  blood  and  fewer  sperma- 
tozoa, but  is  thicker  and  more  gelatinous  than  normal, 
and,  if  obtained  pure  by  expression  with  the  finger, 
shows  a  tendency  to  coagulate.  There  are  often  neuras- 
thenic and  other  symptoms  described  in  connection  with 
chronic  prostatitis.  In  mild  cases  there  may  be  few  or 
no  symptoms  except  when  the  condition  is  intensified  as 
a  result  of  coitus,  sexual  stimulation,  or  other  causes  of 
congestion  of  this  region. 

If  the  bladder  be  full  and  counter-pressure  be  made 
above  the  pubes,  the  finger  in  the  rectum  will  reach, 
just  above  the  prostate  and  to  either  side,  a  considerable 
portion  of  the  seminal  vesicle,  which  in  acute  cases  is 
swollen,  hot,  throbbing,  and  sensitive,  and  in  subacute 
cases  is  distended  with  abnormally  thickened  secretion 
and  is  tender  on  pressure.  (The  normal  vesicle  can 
with  difficulty  be  recognized  by  the  finger  in  the  rectum.) 
The  condition  of  the  prostate  should  be  determined 
before  examining  the  vesicle.  Under  favorable  circum- 
stances acute  vesiculitis  subsides  in  from  two  to  four 
weeks,  and  usually  terminates  in  resolution ;  but  it  may 
result  in  abscess  or  be  followed  by  chronic  inflam- 
mation. 

Treatment. — In  acute  vesiculitis  the  treatment  is  that 
of  acute  prostatitis — namely,  absolute  rest,  hot  applica- 
tions, anodynes,  and  general  treatment  of  the  patient. 
Pressure  upon  the  vesicle  or  frequent  local  examinations 
should  be  avoided,  for  fear  of  rupturing  the  vesicle  or 
encouraging  suppuration.  To  prevent  traction  on  the 
cord,  the  scrotum  should  be  supported  on  the  pubes  as 
in  epididymitis.  If  abscess  forms,  the  treatment  is  surgi- 
cal, as  in  prostatic  and  periprostatic  abscess. 


CYSTITIS.  469 

In  chronic  vesiculitis,  sexual  rest,  hygiene,  and  con- 
stitutional treatment  are  of  the  greatest  importance. 
Iodide  of  potassium,  mercury,  and  especially  cod-liver 
oil  seem  to  favor  resolution.  In  cases  of  long  standing 
in  which  neurotic  symptoms  predominate,  change  of 
scene  and  climate  combined  with  other  measures  for  im- 
proving the  general  health  are  necessary.  Frequent  irri- 
gation of  the  rectum  with  hot  water  furnishes  the  most 
satisfactory  local  treatment.  The  method  of  "  stripping  " 
the  vesicle,  advocated  by  Fuller,  may  be  of  occasional 
value  in  selected  cases.  It  should  be  employed  in 
chronic  and  indolent  conditions  only,  and  then  with  the 
greatest  caution,  for  fear  of  exciting  an  acute  vesiculitis, 
epididymitis,  or  prostatitis. 

CYSTITIS. 

If,  during  gonorrhoea  or  gleet,  the  posterior  urethra 
is  involved,  the  inflammation  may  readily  extend  to  the 
adjacent  mucous  membrane  of  the  bladder.  Such  a 
cystitis,  though  it  may  include  all  the  vesical  membrane, 
is  usually  limited  to  the  surface  about  the  urethral  orifice, 
the  region  commonly  known  as  the  neck  of  the  bladder. 
It  is  probably  due  to  simple  extension  of  the  inflamma- 
tion from  the  urethra  or  to  pus-infection,  and  not  to 
invasion  of  the  membrane  by  gonococci,  since  cystitis 
accompanying  gonorrhoea  is  usually  much  more  amen- 
able to  treatment  than  is  the  primary  disease.  It  is 
often  classed  as  a  mixed  infection,  though  gonococci 
have  never  been  demonstrated  in  the  tissues  of  the 
bladder.  The  exciting  causes  of  this  form  of  cystitis 
are  those  of  posterior  urethritis,  and  they  are  found 
chiefly  in  such  acts,  surroundings,  treatment,  etc.  as  tend 
to  congest  or  irritate  the  deep  urethra  or  to  convey  pus 
from  the  urethra  to  the  bladder. 

Symptoms. — The  symptoms  are  essentially  those 
of  posterior  urethritis.  They  may  be  very  mild  and 
scarcely  noticeable,  or  so  severe  that  there  is  a  constant, 
almost  irresistible,    desire    to   urinate,  with   violent  te- 


47°      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

nesmus  and  the  expulsion  every  few  minutes  of  a  few 
drops  of  urine  mixed  with  pus  and  blood.  Between 
these  two  extremes   the   symptoms   may  vary   greatly. 

There  is  frequently  a  feeling  of  weight  and  discomfort 
in  the  perineum,  with  pains  which  radiate  to  the  penis, 
testicles,  groins,  and  back.  The  pubic  and  hypogastric 
regions  are  often  tender  and  sensitive.  In  severe  cases, 
in  those  of  long  duration,  and  especially  in  those  com- 
plicated by  the  presence  of  stricture  or  enlarged  prostate, 
there  may  be  atony  of  the  bladder-walls  and  partial 
retention  of  urine.  If  unrelieved,  this  condition  is 
usually  followed  by  ammoniacal  decomposition  of  the 
urine,  which  then  has  a  strongly  fetid  and  ammoniacal 
odor,  and  contains  a  quantity  of  thick,  viscid  sediment 
that  adheres  to  the  bottom  and  sides  of  the  vessel  in 
which  the  urine  is  voided.  Such  urine  is  necessarily 
irritating  to  the  mucous  membrane  of  the  bladder,  and 
increases  the  severity  of  the  inflammation. 

Constitutional  symptoms  are  usually  slight;  but  if 
large  areas  of  the  vesical  mucous  membrane  be  involved, 
there  may  be  chills,  fever,  and  other  systemic  disturb- 
ances. Such  symptoms,  however,  appearing  somewhat 
suddenly  during  the  course  of  cystitis,  should  always 
lead  the  physician  to  suspect  the  added  presence  of 
pyelitis.  There  is  often  more  or  less  of  the  mental  dis- 
tress common  to  inflammatory  disorders  of  the  genito- 
urinary tract.  As  in  other  complications  of  urethritis, 
the  urethral  discharge  diminishes  or  disappears  entirely 
during  the  course  of  the  new  disorder.  Cystitis  may 
vary  in  duration  from  a  few  days  to  several  weeks  or 
months,  and  may  terminate  in  complete  resolution  or  in 
some  of  the  chronic  forms  of  the  disease. 

Diagnosis.  —  The  subjective  symptoms  in  cystitis, 
prostatitis,  and  posterior  urethritis  are  so  much  alike  that 
they  should  never  be  relied  upon  for  a  diagnosis.  Rectal 
examination  will  determine  the  presence  or  absence  of 
prostatitis  or  seminal  vesiculitis,  and  careful  examinations 
of  the  urine  should  decide  if  the  inflammation  has  ex- 


CYSTITIS.  471 

tended  from  the  pars  posterior  to  the  bladder,  for  gonor- 
rhoea! cystitis  without  posterior  urethritis  rarely,  if  ever, 
exists. 

Thompson's  two-glass  method,  as  described  in  con- 
nection with  Acute  Posterior  Urethritis,  should  be  used, 
though  it  is  often  desirable  to  have  the  urine  passed  in 
three  separate  glasses.  If  the  inflammation  be  limited  to 
the  posterior  urethra,  there  will  be  times — when  the  urine 
has  been  retained  in  the  bladder  for  but  a  few  minutes, 
possibly  half  an  hour  or  an  hour — when  the  first  portion 
of  urine  alone  will  contain  pus,  the  other  portions  being 
clear.  When  this  occurs,  cystitis  may  be  excluded.  If 
the  vesical  neck  be  also  involved,  the  first  glass  will  con- 
tain most  of  the  pus,  but  all  the  urine  will  be  more  or 
less  clouded.  If  the  cystitis  be  more  extensive,  the 
quantity  of  pus  will  be  greater,  and  during  the  intervals 
of  urination  it  will  settle  to  the  base  of  the  bladder.  In 
this  case  the  amount  of  mucus  and  pus  in  the  first  glass 
depends  on  the  activity  of  the  inflammation  in  the  pos- 
terior urethra  and  at  the  vesical  neck ;  the  second  glass 
contains  the  more  or  less  clouded  urine  from  the  upper 
part  of  the  bladder ;  while  the  urine  in  the  third  glass 
contains  the  mucus  and  pus  that  has  collected  at  the 
base  of  the  bladder,  and  is  therefore  more  heavily  clouded 
than  that  in  either  of  the  other  two  glasses. 

If  in  cystitis  the  urine  be  acid  in  reaction,  as  it  may  be 
in  the  early  stages,  and  be  allowed  to  stand  in  a  glass  for 
a  few  minutes,  two  layers  of  precipitate  will  form.  The 
first  layer,  that  at  the  bottom,  is  composed  chiefly  of 
pus,  is  white,  more  or  less  dense,  and  crumbly  in  appear- 
ance. Above  this  is  a  looser,  flocculent  or  cloudy  layer 
of  mucus  and  muco-pus.  This  upper  layer  forms  more 
slowly,  but  soon  settles  sufficiently  to  leave  a  clear  layer 
of  urine  at  the  top.  In  the  more  severe  as  well  as  in  the 
older  forms  of  cystitis  the  urine  is  usually  neutral  or 
alkaline  in  reaction.  As  the  degree  of  alkalinity  in- 
creases the  pus  and  mucus  form  a  thicker,  glairy,  stringy 
substance  which  adheres  to  the  membrane  of  the  bladder 


472      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

and  to  the  vessel  in  which  it  is  placed.  It  cannot  be 
dropped  from  one  test-tube  to  another,  but  goes  over  in 
stringy  masses.  This  appearance  is  most  marked  in 
ammoniacal  decomposition  of  the  urine,  which  then  not 
only  has  a  foul  odor  and  contains  pus,  but  also  shows 
under  the  microscope  large  numbers  of  micro-organisms, 
amorphous  phosphates,  and  coffin-lid,  triple-phosphate 
crystals.  This  condition  of  the  urine  is  not  found  unless 
cystitis  is  present. 

During  the  course  of  cystitis,  pyelitis  may  occur 
without  additional  symptoms,  so  that  in  every  case  in 
which  the  urine  constantly  contains  pus  the  possible 
presence  of  pyelitis  should  be  considered. 

Treatment. — The  details  of  treatment  are  practically 
those  of  acute  prostatitis.  The  chief  indications  are  met 
by  rest  in  bed,  divided  doses  of  calomel  with  saline  laxa- 
tives, a  milk  diet,  large  dilution  of  the  urine  with  bland 
drinks,  hot  local  applications  and  hot  baths,  and  ano- 
dynes to  relieve  pain  and  tenesmus.  The  best  urinary 
antiseptic  is  urotropin.  From  3  to  8  grains  in  capsule, 
given  every  three  or  four  hours,  and  followed  imme- 
diately by  a  large  draught  of  water,  will  usually  clear 
the  urine  in  a  few  days.  Methylene  blue  sometimes  acts 
well.  It  is  not  desirable  to  render  the  urine  alkaline,  as 
that  would  favor  ammoniacal  decomposition.  Boric 
acid  or  salol  in  doses  of  5  or  10  grains  every  three  or 
four  hours  is  valuable  in  sterilizing  the  urine  and  pre- 
venting decomposition.  Citrate  or  acetate  of  potash  in 
10-  to  20-grain  doses  three  or  four  times  a  day  is  some- 
times of  service  as  a  diuretic.  Balsam  of  copaiba  and 
oil  of  sandalwood  are  often  highly  efficacious  in  reducing 
the  active  symptoms. 

If  the  inflammation  continues  and  becomes  chronic, 
the  treatment  is  that  of  chronic  or  catarrhal  cystitis  from 
other  causes. 

PYELITIS. 

Inflammation  of  the  pelvis  and  calices  of  the  kidney 
occasionally  follows  gonorrhoea!  cystitis.     Its  occurrence 


PYELITIS.  473 

is  favored  by  the  presence  of  stricture,  enlarged  prostate, 
or  any  interference  with  the  free  outward  flow  of  urine. 
Cachexia,  bad  hygiene,  and  alcoholic  excesses  may  also 
favor  its  development.  It  is  possibly  due  at  times  to  the 
gonococcus  toxines. 

Symptoms.  —  This  complication  may  develop  in- 
sidiously, and  until  severe  enough  to  affect  the  general 
health  it  may  present  no  symptoms  in  addition  to  those 
of  cystitis.  In  the  majority  of  cases,  however,  there  is 
pain,  of  a  dull,  burning  character,  in  the  back  and  the 
loins,  extending  possibly  to  the  bladder,  testicles,  peri- 
neum, and  thighs.  The  pain  is  increased  by  pressure 
over  the  kidneys  or  by  active  exercise.  There  is  usually 
some  fever  accompanied  by  chills,  that  may  recur  with 
a  regularity  suggesting  malaria. 

Diagnosis. — The  sudden  appearance,  during  cystitis, 
of  constitutional  disturbances  should  suggest  pyelitis. 
Other  symptoms  are  of  value,  but  the  diagnosis  rests 
chiefly  upon  examinations  of  the  urine.  In  pyelitis  the 
urine  is  decidedly  acid  unless  modified  after  reaching  the 
bladder.  The  pus  is  intimately  mixed  with  the  urine, 
and  on  standing  settles  to  the  bottom  in  a  greenish,  com- 
pact, creamy  or  oily-looking  layer.  If  decomposition 
in  the  bladder  is  prevented,  the  urine  is  not  only  acid, 
but  on  standing  remains  so  for  several  days,  and  bacteria 
do  not  readily  develop  in  it,  as  they  do  in  urine  from 
cystitis. 

Albumin  is  present  in  larger  amount  than  would  be 
furnished  by  the  pus  alone.  Under  the  microscope  the 
urine  shows,  besides  pus  and  mucus,  cylindrical  masses 
of  pus-cells,  occasional  hyaline  or  granular  casts,  some 
red  blood-corpuscles,  and  epithelial  cells  that  in  some 
cases  may  be  recognized  as  peculiar  to  the  kidney. 
Later  in  the  disease  there  are  sudden  changes  from 
day  to  day  in  the  amount  of  pus  present  in  the  urine. 
Finally,  in  doubtful  cases  the  bladder  may  be  washed 
out  thoroughly  and  the  urine  allowed  to  collect  for  fifteen 
or  twenty  minutes,  when  it  is  drawn  from  the  bladder 


474      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

with  a  catheter ;  if  pus  is  evenly  mixed  with  the  urine,  it 
undoubtedly  comes  from  the  kidney. 

By  those  having  the  requisite  skill,  catheterization  of 
the  ureters  or  cystoscopy  may  be  employed  for  the  pur- 
pose of  accurate  diagnosis.  A  simpler  method  than 
either  of  the  preceding,  and  one  which  in  the  majority 
of  cases  serves  the  purpose  equally  well,  is  found  in  the 
use  of  an  instrument  known  as  Harris'  device  for  col- 
lecting urine  from  the  ureters  separately. 

Treatment. — The  treatment  of  cystitis  should  be  con- 
tinued in  the  form  of  rest  in  bed,  diluent  drinks,  diuretics, 
anodynes,  and  the  avoidance  of  all  stimulating  articles 
of  food  and  drink.  Urotropin  should  be  given  as  in 
cystitis,  and  usually  produces  a  prompt  clearing  of  the 
urine.  Hot  baths,  with  hot  fomentations  or  cupping 
over  the  region  of  the  kidney,  often  aid  in  relieving 
pain.  Copaiba,  boric  acid,  or  salol  can  often  be  used 
to  advantage.  Under  such  treatment,  and  with  the  re- 
moval of  the  cause,  this  form  of  pyelitis,  usually  termi- 
nates in  prompt  recovery,  though  it  may  progress  to 
graver  stages  of  the  disease  or  may  become  chronic. 

FOLLICULITIS. 

In  most  cases  of  gonorrhoea  inflammation  extends  to 
some  of  the  follicles  and  glands  opening  into  the  urethra. 
This  complication  may  occur  in  any  part  of  the  canal,  but 
is  most  frequent  in  the  fossa  navicularis,  bulb,  or  pros- 
tatic portion,  where  the  glands  are  large  and  numerous 
If  the  inflammation  is  mild  in  type,  the  follicle  becomes 
slightly  swollen  and  tender  and  discharges  pus  into  the 
urethra.  This  condition  may  be  present  in  a  number  of 
glands  during  an  acute  gonorrhoea  without  adding  ap- 
preciably to  the  urethral  symptoms,  and  therefore  without 
being  recognized,  but  it  can  easily  be  demonstrated 
when  the  follicles  at  the  orifice  of  the  urethra  are  in- 
volved. The  lips  of  the  meatus  are  then  red  and  swollen ; 
if  their  surfaces  be  cleansed  and  slight  pressure  be  made 


PERIURETHRITIS.  475 

upon  them,  pus  will  be  seen  escaping  from  the  narrow 
openings  of  the  follicles. 

If  the  inflammation  is  more  severe,  the  duct  may  be- 
come occluded  by  the  swelling  of  the  mucous  mem- 
brane, and  the  follicle  or  gland  becomes  a  cyst,  which 
in  most  instances  disappears  after  discharging  its  con- 
tents of  pus  into  the  urethra.  At  first  no  larger  than  a 
pin-head,  and  slightly,  if  at  all,  painful,  it  may  remain 
stationary  for  some  time  as  a  small  firm  nodule;  or  it 
may  grow  slowly,  remain  inactive  for  months  or  years, 
and  finally  be  absorbed;  or  it  may  increase  more  rapidly, 
become  sensitive,  soften,  and  discharge  both  internally 
and  externally,  leaving  a  fistula  which  may  persist  in- 
definitely. When  one  of  these  cysts  opens  into  the 
urethra,  it  may  discharge  its  contents  and  refill  repeatedly 
or  may  become  irritated  by  the  urine  and  result  in  peri- 
folliculitis. Folliculitis  may  persist  in  subacute  form 
and  furnish  a  urethral  discharge  long  after  the  rest  of 
the  urethral  membrane  has  recovered. 

Treatment. — If  the  inflammatory  symptoms  are  acute, 
rest  and  hot  applications  should  be  employed.  Under 
this  treatment  the  majority  of  cases  recover.  When 
fluctuation  is  detected,  an  incision  should  be  made,  to 
allow  the  escape  of  the  pus  externally  and  to  prevent  an 
opening  into  the  urethra.  Later  the  cyst  may  be  enucle- 
ated entirely  or  the  sac  may  be  injected  with  a  drop  of 
pure  carbolic  acid  or  a  strong  solution  of  nitrate  of  silver. 
When  a  cyst  opens  into  the  urethra,  the  cautious  use  of 
the  full-sized  steel  sound  is  of  service  in  keeping  the  sac 
empty.  In  indolent  cases  absorption  may  be  promoted 
by  the  external  use  of  oleate  of  mercury  in  strength  vary- 
ing from  2  to  10  per  cent. 

PERIURETHRITIS. 

As  an  unusual  result  of  folliculitis  the  inflammation 
extends  beyond  the  limits  of  the  follicle  or  gland  and 
invades  the  surrounding  cellular  tissue.  This  tissue 
may  also  be  infected  directly  through  rupture  or  abra- 


476      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

sion  of  the  mucous  membrane.  The  process  may- 
terminate  in  a  circumscribed  abscess  or,  very  rarely, 
in  suppuration  and  destruction  of  the  large  portions 
of  the  spongy  and  cavernous  bodies  of  the  penis. 
The  commonest  sites  of  periurethritis  are  in  the  fossa 
navicularis,  where  the  abscess  generally  forms  on  one 
side  of  the  fraenum,  and  in  the  bulb,  where  it  usually 
develops  in  the  central  line.  Beginning  in  the  bulb,  the 
inflammation  may  involve  the  root  of  the  penis  and  the 
scrotum,  or  rarely  the  entire  perineum  and  the  tissues 
about  the  anus.  The  abscess  usually  opens  externally, 
but  it  may  discharge  into  the  urethra,  and  may  result  in 
urinary  fistula  or  in  infiltration  of  urine  through  large 
portions  of  the  surrounding  tissues,  causing  suppuration 
and  destruction  of  these  parts.  The  conditions  favorable 
to  infiltration  and  abscess-formation  are  found  just  back 
of  a  stricture,  where  the  urethral  walls  are  damaged  and 
weakened.  The  abscesses  are  more  or  less  painful,  and 
may  interfere  by  pressure  upon  the  urethra  with  the 
passage  of  urine.  When  suppuration  is  extensive  the 
constitutional  symptoms  may  be  marked.  The  cica- 
trices which  are  left  after  healing  of  such  abscesses  may 
be  slight,  or  so  extensive  and  deforming  that  an  erection 
of  the  penis  is  attended  by  crooking  or  bending  of  the 
organ,  and  possibly  by  pain. 

Treatment. — Absolute  rest  of  the  genital  organs,  and, 
when  possible,  of  the  entire  body,  is  of  the  greatest  im- 
portance. To  this  end  a  light  diet,  gentle  evacuation 
of  the  bowel,  absence  of  all  sexual  excitement,  and 
horizontal  position  of  the  body  are  necessary.  If  the 
inflammation  be  recognized  early,  it  may  be  aborted 
by  cold  compresses  and  inunctions  of  the  oleate  of  mer- 
cury. If  suppuration  begin,  boric-acid  fomentations 
should  be  constantly  applied,  and  an  early,  often  a  deep, 
incision  is  necessary  to  evacuate  the  pus  and  to  prevent 
an  opening  into  the  urethra.  It  is  neither  wise  nor  safe 
to  wait  for  fluctuation  before  using  the  knife.  If  there 
are  other  evidences  of  suppuration,  or  if  the  inflammation 


co  wperitis.  477 

has  been  in  progress  for  a  week,  it  is  better  to  make  a 
free  incision  than  to  run  the  risk  of  allowing  the  abscess 
to  open  into  the  urethra.  This  is  especially  true  of  an 
abscess  situated  in  the  bulb,  where  fluctuation  is  not 
readily  detected,  and  where  an  internal  opening  is  liable 
to  be  followed  by  extensive  infiltration  of  urine  and  by 
perineal  abscess.  After  discharging,  the  cavity  should 
be  cleaned  daily  and  packed  loosely  with  iodoform  gauze 
until  healthy  granulations  are  obtained.  All  manipu- 
lations should  be  performed  gently  and  carefully,  lest 
communication  between  the  gland  and  the  urethra  be  re- 
established and  a  urinary  fistula  be  formed. 

When  an  abscess  ruptures  into  the  urethra,  the  treat- 
ment consists  in  rest,  fomentations,  and  a  position  that 
will  favor  drainage.  The  case  must  be  watched  carefully, 
and  as  soon  as  local  swelling,  pain,  interference  with  uri- 
nation, or  fever  indicates  extravasation  of  urine  and  fur- 
ther suppuration,  an  external  opening  should  at  once  be 
made.     The  further  treatment  is  that  of  urinary  fistula. 

Resolution  may  be  incomplete,  leaving  a  small,  indo- 
lent nodule  which  persists  for  months.  Such  a  condi- 
tion will  usually  disappear  under  inunctions  of  oleate  of 
mercury.     If  not,  it  may  be  excised. 

COWPERITIS. 

Inflammation  of  Cowper's  glands  is  a  rare  complication 
of  gonorrhoea.  It  may  occur  after  the  second  week,  but 
it  usually  begins  between  the  third  and  fourth  weeks. 
The  patient  complains  of  a  sticking  pain,  of  tension,  or 
of  tenderness  in  the  perineum  on  pressure  (as  in  sitting). 
On  examination  a  deep-seated,  round  or  oval,  tender 
nodule,  about  the  size  of  a  bean,  is  discovered  midway 
between  the  anus  and  the  posterior  border  of  the  scrotum 
and  at  one  side  of  the  raphe.  It  is  sometimes  pear-shaped, 
in  which  case  the  larger  end  is  toward  the  anus.  The 
tumor  usually  grows  rapidly  in  size,  and  by  pressure 
upon  the  urethra  may  interfere  with  micturition.  The 
surrounding  tissue  becomes  involved,  so  that  the  tumor 


4/8      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

loses  its  sharp  outline,  becomes  doughy  or  boggy  to  the 
touch,  and  may  extend  somewhat  beyond  the  median 
line.  Suppuration  is  attended  by  local  throbbing  pain 
and  by  chills  and  fever.  Many  mild  cases  undergo  reso- 
lution, but  a  large  abscess  may  form  and  may  open  ex- 
ternally or  internally.  In  the  latter  case  there  is  great 
danger  of  infiltration  of  urine  and  deep  perineal  abscess. 
Treatment. — The  treatment  is  that  of  periurethral 
inflammation  and  abscess. 

LYMPHANGITIS. 

In  severe  cases  of  gonorrhoea  more  or  less  lymphangi- 
tis is  common.  In  its  simplest  and  mildest  form  there 
are  no  subjective  sensations,  but  one  or  more  lymphatics, 
usually  on  the  dorsum  of  the  penis,  can  be  felt  beneath 
the  skin  as  small  indurated  cords.  Occasionally  such  a 
cord  may  be  traced  to  the  groin.  If  the  inflammation 
runs  a  little  higher,  perilymphangitis  results  and  is  mani- 
fested by  reddish  streaks  along  the  course  of  the  lym- 
phatics, which  may  be  knotted  and  tender.  There  may 
be  a  more  diffuse  redness  of  the  skin,  which  is  then  cedem- 
atous,  swollen,  hot,  and  sensitive.  The  inguinal  glands 
may  become  swollen,  tense,  and  painful. 

Treatment. — Rest,  elevation  of  the  penis,  and  boric- 
acid  fomentations  are  usually  all  the  treatment  necessary. 
As  a  rule,  the  inflammation  terminates  in  resolution.  If 
pus  forms,  it  should  be  evacuated  early  to  prevent  bur- 
rowing in  the  loose  tissues,  as  a  considerable  portion,  or 
even  all,  of  the  skin  and  the  subcutaneous  tissue  of  the 
penis  could  be  thus  destroyed. 

ADENITIS. 

During  a  severe  case  of  gonorrhoea  it  is  not  uncom- 
mon for  one  or  more  of  the  inguinal  glands  to  become 
slightly  swollen  and  tender ;  but  suppuration  is  quite 
unusual,  and  when  it  does  occur  the  abscess  heals 
kindly  after  discharging  the  pus,  which  is  not  auto- 
inoculable. 


GONORRHEAL   RHEUMATISM.  479 

Treatment  for  the  adenitis,  aside  from  that  given  for 
the  gonorrhoea,  is  usually  unnecessary.  When  the 
gland  first  begins  to  swell  and  become  sensitive,  it  may 
be  well  to  paint  the  overlying  skin  with  tincture  of 
iodine  or  to  apply  a  2  per  cent,  oleate  of  mercury.  If 
pain  and  swelling  become  pronounced,  rest,  hygiene, 
and  boric-acid  fomentations  give  relief.  If  pus  forms, 
the  abscess  should  be  opened  and  treated  on  surgical 
principles.  Scraping  is  rarely  necessary,  since  the 
cavity  usually  heals  kindly  and  rapidly  under  daily 
cleansing  and  packing  with  iodoform  gauze. 


GONORRHEAL   RHEUMATISM. 

In  certain  individuals  gonorrhoeal  infection  is  always 
attended  by  a  complication  known  as  "  gonorrhoeal 
rheumatism."  These  individuals  are  not,  as  a  rule, 
subject  to  other  forms  of  rheumatism. 

Etiology. — Various  theories  are  offered  to  explain 
the  cause  of  this  disease  and  its  relation  to  gonor- 
rhoeal infection,  but  none  of  them  has  yet  proved  satis- 
factory for  the  majority  of  cases.  There  can  be  little 
question  that  in  some  instances  the  disease  is  the  result 
of  a  metastatic  infection,  the  gonococci  being  carried 
from  the  urethra  to  the  affected  joint  by  the  blood. 
The  gonococcus  has  been  found  not  only  in  the  joints, 
endocardium,  and  other  tissues,  but  also  in  the  blood 
of  these  patients.  From  these  sources  the  gonococcus 
has  been  successfully  cultivated  and  pure  cultures  in- 
troduced into  a  normal  urethra,  with  the  production  of 
a  true  gonorrhoea.  On  the  other  hand,  the  majority  of 
attempts  to  demonstrate  the  gonococcus  in  the  blood  or 
in  other  organs  than  the  urethra  have  failed.  In  some 
instances  pus  and  other  micro-organisms  have  been 
found,  either  alone  or  associated  with  gonococci.  The 
condition  may  be  due  at  times  to  gonorrhoeal  or  other 
toxines. 

The  disease  does  not  occur  with  non-infectious   ure- 


480      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

thritis,  but  it  has  resulted  from  gonorrhceal  infection 
of  the  conjunctiva  or  vagina,  and  therefore  cannot  be 
due  simply  to  urethral  irritation.  It  occurs  in  about 
2  per  cent,  of  all  cases  of  gonorrhoea,  and  it  is  much 
more  frequent  in  men  than  in  women.  A  rheumatic 
diathesis  and  the  usual  causes  of  the  commoner  ar- 
ticular rheumatism  have  no  apparent  influence  in  the 
production  of  gonorrhceal  rheumatism ;  while  an  indi- 
vidual who  has  once  had  this  complication  of  gonor- 
rhoea rarely  escapes  in  future  infections,  even  when 
every  precaution   is  taken  to  prevent  its  occurrence. 

Symptoms. — The  period  at  which  the  disease  appears 
varies,  but  in  about  three-fourths  of  all  cases  it  occurs 
during  the  third  or  fourth  week  of  gonorrhoea.  It  may 
be  much  later,  and  has  been  reported  as  early  as  the 
fifth  day.  It  does  not  have  the  effect — as  do  most  of 
the  complications  of  gonorrhoea — of  diminishing  the 
urethral  discharge ;  on  the  contrary,  changes  in 
the  degree  and  intensity  of  the  urethral  inflammation 
are  usually  promptly  followed  by  similar  changes  in  the 
rheumatic  symptoms. 

In  about  40  per  cent,  of  all  cases  the  disease  is 
limited  to  a  single  joint,  and  when  polyarticular  it  is 
usually  confined  to  two  or  three  joints,  which  it  attacks 
in  succession,  and  not  simultaneously.  Finger  collected 
statistics  showing  the  joints  affected  in  376  cases  as 
follows:  Knee,  136;  tibio-tarsal,  59;  wrist,  43;  finger, 
35;  elbow,  25;  shoulder,  24;  hip,  18;  maxillary,  14; 
metatarsus,  7  ;  sacro-iliac,  4 ;  sterno-clavicular,  4  ;  chon- 
dro-costal,  2 ;  intervertebral,  2 ;  crico-arytenoid,  2 ; 
peroneo-tibial,  I.  Besides  the  joints,  synovial  bursae 
and  the  synovial  sheaths  of  tendons  and  muscles  may 
be  involved. 

All  attempts  to  classify  the  widely  varying  symptoms 
of  gonorrhceal  rheumatism  in  distinct  types  have  proven 
unsatisfactory.  The  classification  here  followed  is  sub- 
stantially that  given  by  Finger : 

1.  Acute  Monarticular  Gonorrheal  Rheumatism. — This 


GONORRHEAL    RHEUMATISM.  48 1 

is  the  most  frequent  form  of  the  disease,  and  usually 
appears  in  one  of  the  large  joints,  most  commonly  the 
knee.  The  local  disorder  may  be  preceded  by  slight 
constitutional  disturbance  and  by  tenderness  of  several 
articulations,  or  the  first  symptoms  may  be  pain  and 
swelling  of  the  affected  joint.  The  tumefaction  usually 
increases  rapidly,  with  sufficient  exudation  to  produce 
considerable  tension.  Pain  is  usually  moderate,  but 
may  be  mild  or  violent.  Fluctuation  is  always  distinct 
Fever — which  may  be  as  high  as  1030  F. — and  other 
systemic  disturbances  are  present  for  a  few  days,  but 
they  rapidly  subside.  The  swelling  and  the  exudate 
remain  and  interfere  with  motion  of  the  joint. 

The  exudate  may  be  wholly  absorbed  in  the  course 
of  a  few  weeks,  complete  recovery  following,  or  there 
may  be  a  relapse  of  the  acute  symptoms — usually  fol- 
lowing exacerbations  of  the  urethritis — which  greatly 
increases  the  natural  tendency  of  the  disease  to  become 
chronic  and  to  terminate  in  hydrarthrosis.  In  rare  in- 
stances the  disease  terminates  in  suppuration,  which  is 
announced  by  its  usual  symptoms — namely,  chills  and 
fever,  an  increase  of  the  local  swelling,  pain  which 
becomes  throbbing  in  character,  and  an  intense  redness 
of  the  skin  covering  the  parts.  The  pus  bursts  through 
the  capsule  and  burrows  between  the  tendons  and  mus- 
cles to  the  surface.  The  usual  result  of  this  process  is 
pyaemia  and  death.  Recovery  with  ankylosis  is  pos- 
sible. 

2.  Acute  Polyarticular  Gonorrheal  Rheumatism. — The 
symptoms  are  those  of  the  preceding  variety,  except 
that  the  disease  involves  two  or  more  joints  and  that  the 
constitutional  disturbances  are  usually  more  pronounced. 
The  latter  may  be  acute  and  severe  for  a  few  days,  but 
they  do  not  last  long.  They  may,  however,  recur  a 
number  of  times  as  new  joints  are  affected  or  following 
exacerbations  of  the  urethritis.  The  fever  does  not 
often  go  above  1030  F.  The  pericardium  and  the  endo- 
cardium are  rarely  implicated.     The  mild  character  and 

31 


482      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

the  brief  duration  of  all  the  general  symptoms,  as  com- 
pared with  the  severity  of  the  local  disorder,  form  a 
striking  feature  of  the  disease. 

The  affection  may  be  limited  to  two — often  symmetri- 
cal— joints,  or  it  may  pass  in  succession  to  three  or 
four  :  the  implication  of  a  larger  number  of  joints  is  ex- 
ceptional. Simultaneous  invasion  of  two  or  more  joints 
is  unusual,  and  the  disease  does  not  travel  rapidly  from 
one  joint  to  another,  nor  does  the  involvement  of  a 
second  joint  hasten  recovery  in  the  first.  Absorption  of 
the  effusion  is  slow,  and,  as  in  the  monarticular  variety, 
the  disease  may  terminate  in  recovery,  in  chronic 
hydrarthrosis,  or  in  pyaemia. 

This  variety  of  the  disorder  resembles  more  than  do 
the  others  simple  inflammatory  rheumatism. 

3.  Subacute  Polyarticular  Gonorrhceal  Rheumatism. — 
This  form  of  the  malady  is  identical  with  the  preceding, 
except  that  the  fever  is  never  higher  than  1010  F.  and 
that  the  subjective  symptoms  are  very  slight.  It  is 
evident  that  a  sharp  dividing-line  cannot  be  drawn 
between  the  two  forms.  Finger  considers  this  variety 
of  the  disease  second  in  order  of  frequency. 

4.  Chronic  Gonorrhceal  Rheumatism  ;  Hydrarthrosis. — 
This  is  a  common  form  of  the  disease,  is  usually  mon- 
articular, and  is  commonly  found  in  the  knee,  the  ankle, 
or  the  elbow.  It  may  follow  the  acute  or  the  subacute 
form,  or  it  may  appear  independently.  In  the  latter  case 
it  often  develops  insidiously,  and  it  may  not  be  noticed 
by  the  patient  until  the  effusion  is  sufficient  to  interfere 
with  motion ;  or  the  effusion  may  take  place  rapidly, 
and  may  be  accompanied  by  some  pain  which  is  in- 
creased on  walking  or  on  other  movements  of  the  joint. 
Fluctuation  may  be  the  sole  evidence  of  the  disease.  If 
the  effusion  be  considerable,  motion  in  the  joint  is  more 
or  less  limited ;  if  the  exudate  be  excessive,  there  may 
be  abnormal  mobility  of  the  joint,  due,  undoubtedly,  to 
loosening  of  the  ligaments.  Absorption  is  occasionally 
rapid,  but  usually  it  is  very  slow  and  the  fluid  may  be 


GONORRHCEAL    RHEUMATISM.  483 

many  months    in  disappearing.      Adhesions    and  other 
deformities  may  leave  an  impaired  joint. 

Fournier's  classification  recognizes  a  form  of  gonor- 
rheal rheumatism  in  which  neither  structural  nor  func- 
tional evidences  of  disease  are  observed,  and  which  may 
present  no  symptoms  other  than  vague,  wandering  or 
persistent  pains  in  some  of  the  larger  joints.  These 
pains  are  very  similar  to  those  sometimes  found  in  the 
early  stages  of  syphilis,  and  they  are  often  very  rebel- 
lious to  treatment.  This  type  is  probably  due  to  a  mild 
toxaemia  caused  by  absorption  of  toxines  from  the  urethra. 

The  synovial  sheaths  of  tendons  connected  with  the 
affected  joints  may  be  involved,  and,  occasionally  they 
are  affected  independently  of  the  joints.  There  is  red- 
ness of  the  skin,  with  a  doughy,  painful  swelling  that 
may  extend  some  distance  along  the  tendon.  Motion  of 
the  muscle  is  prevented  by  the  pain,  which  may  persist 
after  the  swelling  disappears.  The  bursa  in  front  of  the 
tendo  Achillis  and  that  beneath  the  inferior  tuberosity 
of  the  os  calcis  are  frequently  involved.  Other  bursae 
are  occasionally  implicated.  Rheumatic  symptoms  are 
sometimes  present  in  the  muscles,  more  especially  in 
those  connected  with  the  affected  joints. 

Ophthalmic  symptoms  are  not  infrequently  present. 
They  are  most  common  in  connection  with  the  poly- 
articular form  of  rheumatism.  In  rare  instances  they 
appear  without  rheumatic  symptoms  in  other  parts  of 
the  body.  The  parts  of  the  eye  that  may  be  affected 
are  the  iris,  the  membrane  of  Descemet,  and  the  con- 
junctiva. The  iritis  presents  symptoms  similar  to  those 
occurring  when  the  affection  results  from  other  causes : 
the  conjunctiva  is  reddened;  the  subconjunctival  capil- 
laries are  injected,  and  can  be  seen  radiating  outward 
from  the  margin  of  the  cornea :  the  iris  is  clouded  and 
discolored,  and  its  movements  are  sluggish  ;  vision  is 
somewhat  impaired  ;  posterior  synechias  may  form  ;  pain 
may  be  severe  or  absent,  but  there  is  usually  photopho- 
bia and  lachrymation. 


484      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

In  inflammation  of  the  membrane  of  Descemet  (aquo- 
capsulitis,  serous  iritis)  the  symptoms  are  less  acute. 
The  fluid  in  the  anterior  chamber  is  clouded  by  the 
presence  of  a  plastic  exudate  and  epithelial  cells  from 
the  iris ;  vision  is  thus  impaired.  Flocculi  may  be 
deposited  on  the  membrane  of  Descemet,  giving  this 
part  of  the  cornea  a  punctate  appearance.  The  iris  may 
be  slow  in  its  movements,  and  exceptionally  synechias 
may  form,  but  other  symptoms  of  iritis  are  wanting. 
This  is  the  commonest  form  of  ophthalmia  associated 
with  gonorrhceal  rheumatism. 

The  conjunctival  form  of  gonorrhceal  rheumatic  oph- 
thalmia, described  by  Fournier,  is  very  rare,  and  is 
simply  a  mild  form  of  conjunctivitis  having  a  scanty, 
muco-purulent  discharge.  The  prognosis  is  entirely 
favorable.  This  form  of  conjunctivitis  must  not  be  con- 
fused with  the  infectious  gonorrhceal  form  (see  table  of 
diagnosis  in   Gonorrhceal  Ophthalmia). 

These  forms  of  ophthalmia  usually  follow  the  course 
of  the  gonorrhoea  on  which  they  are  dependent.  As  a 
rule,  they  affect  both  eyes,  but  not  at  the  same  time. 
The  prognosis  is  favorable,  and  the  only  results  to  be 
feared  are  the  adhesions  which  may  follow  iritis,  or, 
rarely,  inflammation  of  the  membrane  of  Descemet. 

Among  the  occasional  and  unusual  complications  of 
gonorrhceal  rheumatism  are  pericarditis  and  endocar- 
ditis. Neuralgia  of  the  sciatic  and  other  nerves  has 
been  reported,  as  well  as  indefinite  spinal  symptoms 
consisting  of  disturbances  of  sensory  and  motor  func- 
tions of  the  nerves.  Purpura,  erythema  multiforme,  and 
other  eruptions  on  the  skin  may  occur  in  connection 
with  the  disease,  though  in  most  cases  the  eruption  is  prob- 
ably due  to  some  drug  given  to  relieve  the  rheumatism. 

Pathology. — Regarding  the  pathology  of  the  disease 
little  is  known.  Post-mortem  examinations  have  been 
made  on  a  few  fatal  pyaemic  cases.  In  some  of  these 
cases  there  were  erosions  of  the  cartilages  and  bones, 
and   even   complete  destruction   of  the  cartilages,  with 


G  ONORRHCEA  L    RUE  UMA  TISM. 


485 


dissection  of  the  periosteum  from  several  inches  of  the 
femur.  Gonococci  were  found  in  some  instances.  In 
more  favorable  cases  puncture  or  incision  of  the  joint 
has  disclosed  a  serous,  sero-fibrinous,  or  sero-purulent 
fluid,  which  in  the  majority  of  cases  contained  cocci 
that  were  apparently  identical  with  gonococci. 

Diagnosis. — When  the  disease  complicates  successive 
gonorrhceal  infections,  or  when  it  is  limited  to  a  single 
joint,  the  diagnosis  is  usually  made  without  difficulty. 
The  following  is  a  table  of  differential  diagnosis  as  given 
by  Fournier,  with  some  modifications  : 


Gonorrhceal  Rheumatism. 

Cause.  —  Gonorrhceal   infection. 

Cold    and    rheumatic    diathesis 

without   influence. 
Rare  in  women. 

Fever  and  systemic  symptoms  usual- 
ly mild  and  often  absent.  Acute 
symptoms,  when  present,  are  of 
brief  duration. 

Often  limited  to  one  joint,  never 
involves  many. 

When  polyarticular,  the  joints  are 

affected   consecutively,   and   not 

simultaneously. 
Moves  from  one  joint  to   another 

less  quickly.     No  delitescence  ; 

no  real  jumping  from  one  joint  to 

another. 
Local  pain  less  intense  and  shorter 

in  duration.      More   relief  from 

rest   and   position.      Pain  often 

slight  or  even  absent. 
Secondary  hydrarthrosis  common. 
No  sweating. 

Urine  not  modified. 

Blood  does  not  furnish  marked 
buffy-coat. 

Cardiac  complications  very  excep- 
tional. 


Simple  Rhetimatism. 

No  relation  to  gonorrhoea.  Habit- 
ual causes  are  cold,  inheritance, 
rheumatic  diathesis,  etc. 

Common  in  the  female,  though  less 
frequent  than  in  the  male. 

P'ever  and  other  systemic  symptoms 
are  almost  always  present  and 
are  much  more  severe  and  more 
prolonged. 

Rarely  limited  to  less  than  two  or 
three  joints ;  may  involve  nearly 
all. 

Simultaneous  involvement  of  several 
joints  is  the  rule. 

Movable,  ambulatory  fluxions; 
rapid  delitescence,  jumping  from 
one  joint  to  another. 

Pains  are  usually  intense,  some- 
times excessive,  last  much  longer, 
and  are  but  partially  relieved  by 
rest  and  position. 

Secondary  hydrarthrosis  rare. 

Abundant  sweats,  usually  acid,  are 
characteristic. 

Urine  specially  modified. 

Blood  forms  a  firm,  concave  clot 
with  buffy-coat. 

Cardiac  complications  frequent. 


486      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

Gonorrheal  Rheumatism.  Simple  Rheumatism. 

Frequently  complicated  by  a  special  Eye  not  affected ;  the  bursse  escape, 

ophthalmia,  synovitis  of  tendon-  as  do  usually  the  sheaths  of  the 

sheaths,  bursae,  etc.      The  latter  tendons, 
localities  may  be  exclusively  im- 
plicated. 

Relapses     are     frequent,    and    are  Relapses  frequent,  but  independent 

usually  dependent   on   exacerba-  of  state   of  urethra.     Can  often 

tion    of  urethritis.       Recurs    al-  be   traced   to   exposure   to    cold, 

most  invariably  with  succeeding  weather-changes,  etc. 
gonorrhceal  infections. 

Treatment. — No  satisfactory  treatment  of  gonorrhceal 
rheumatism  has  yet  been  found.  In  the  acute  and  sub- 
acute stages  salicylate  of  sodium,  salol,  and  occasionally 
phenacetin,  are  of  some  value.  Probably  the  most  use- 
ful remedy  is  oil  of  gaultheria,  which  was  first  recom- 
mended in  this  disorder  by  Taylor.  It  may  be  given  in 
capsules  or  in  emulsion  in  doses  of  from  5  to  20 
drops  four  times  a  day.  Rest,  a  light  diet,  tonics,  and 
hygienic  measures  are  always  indicated.  Anodynes 
are  rarely  needed.  Elimination  should  be  encouraged 
through  the  bowels,  kidneys,  and  skin.  Calomel  or  blue 
mass,  followed  by  salines,  diuretics  with  large  quantities 
of  water,  and  occasionally  pilocarpine,  are  indicated. 
The  urine  should  be  kept  unirritating  by  the  use  of 
bland  drinks  and,  when  necessary,  of  alkalies.  Copaiba, 
sandalwood,  and  cubebs  are  of  decided  benefit  when 
they  lessen  the  urethral  inflammation,  since  changes  for 
the  better  or  the  worse  in  the  rheumatic  symptoms 
usually  closely  follow  similar  changes  in  the  urethritis. 
For  this  reason  local  treatment  of  the  urethra  and  all 
possible  sources  of  urethral  irritation  should  carefully 
be  avoided.  In  chronic  stages,  mercury  and  iodide  of 
potassium  are  often  of  service  in  promoting  resolution. 

The  most  satisfactory  results  usually  come  from  local 
treatment  of  the  joint.  During  the  acute  stages  absolute 
rest,  with  the  constant  application  of  fomentations  or 
poultices  as  hot  as  can  be  tolerated,  will  usually  give 
prompt  relief.     In  unusual  cases,  when  the  pain  is  exces- 


GONORRHCEAL    CONJUNCTIVITIS.  487 

sive,  tobacco  or  opium  and  belladonna  may  be  added 
to  the  fomentations.  Blistering  of  the  surface  and  fre- 
quent applications  of  the  Paquelin  cautery  are  excellent 
methods  in  both  acute  and  subacute  cases.  To  promote 
absorption  in  subacute  and  chronic  cases,  the  surface 
over  the  joint  may  be  painted  with  iodine  or  rubbed  with 
oleate  of  mercury  in  lanolin  (2  to  10  per  cent.) ;  or  mas- 
sage, friction,  and  electricity  may  be  found  of  benefit. 
All  forms  of  local  treatment  should  be  supplemented  by 
firm,  even  pressure  secured  by  a  properly  applied  roller 
or  elastic  bandage  or  by  an  elastic  cap  or  splint  made 
to  fit  the  joint.  In  chronic  and  persistent  cases  it  may 
be  necessary  to  immobilize  the  joint  in  a  plaster  cast. 
Aspiration  of  the  joint  followed  by  irrigation  with  a  2 
per  cent,  solution  of  carbolic  acid  may  prove  effective 
when  other  measures  fail.  In  the  rare  cases  in  which 
suppuration  occurs  the  treatment  is  entirely  surgical. 

The  ophthalmic  symptoms  call  for  little  special  treat- 
ment. In  iritis  a  solution  of  atropine  (gr.  ij  to  3j)  should 
be  used  to  keep  the  pupil  dilated  and  to  prevent  adhesions. 
All  other  treatment  is  chiefly  symptomatic.  A  light  diet, 
rest,  correct  hygiene,  and  proper  treatment  of  the  ure- 
thritis are  always  in  order.  Systemic  disorders,  such 
as  endocarditis,  pleurisy,  peritonitis,  neuritis,  and  menin- 
gitis, which  occasionally  accompany  gonorrhoea,  should 
receive  such  additional  treatment  as  is  indicated  in  these 
conditions  when  occurring  independently. 

Prognosis. — With  thorough  and  persistent  treatment 
most  cases  recover.  Fatal  cases  are  few,  but  the  disease 
has  a  decided  tendency  to  continue  as  a  chronic  hydrar- 
throsis.    The  prognosis  should  therefore  be  guarded. 

GONORRHCEAL  CONJUNCTIVITIS. 

Synonyms. — Gonorrhceal  ophthalmia  ;  Blennorrhagic 
ophthalmia ;  Purulent  ophthalmia ;  Blennorrhagic  con- 
junctivitis; Purulent  conjunctivitis. 

In  the  adult  gonorrhceal  conjunctivitis  is  fortunately 
rare,  but  when  it  does  occur  it  is  an  exceedingly  grave 


488      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

disease,  since  it  usually  results  in  impairment  or  destruc- 
tion of  vision  in  the  affected  eye. 

Etiology. —  Direct  infection  of  the  conjunctival  mem- 
brane with  pus  containing  gonococci  is  apparently  the 
sole  cause.  The  smallest  particle,  however,  of  such  pus, 
even  after  it  has  been  dried  for  some  days,  is  sufficient  to 
cause  infection.  Successful  inoculation  of  the  urethra 
has  been  accomplished  with  gonorrhceal  pus  diluted  to 
one  part  in  a  thousand.  These  statements  apply  only  to 
gonorrhceal  conjunctivitis,  and  not  to  other,  usually 
milder,  forms  of  purulent  conjunctivitis.  In  most  cases 
the  disease  of  the  conjunctiva  is  found  in  individuals  suf- 
fering from  gonorrhoea,  and  who  have  conveyed  some  of 
the  discharge  from  the  genitals  to  the  eye ;  but  pus  from 
any  form  of  gonorrhceal  inflammation  may  be  carried  by 
means  of  fingers,  handkerchiefs,  towels,  etc.,  and  produce 
the  disease  in  any  eye  with  which  they  come  in  contact. 
In  this  way  the  eyes  of  the  physician,  nurse,  or  companion 
are  occasionally  infected. 

Symptoms. — The  period  of  incubation,  or  the  time 
which  elapses  between  the  infection  and  the  first  apparent 
symptoms,  varies  from  a  few  hours  to  two  or  three  days. 
Usually  the  duration  of  this  period  cannot  be  determined, 
since  the  infection  is  rarely  recognized  at  the  time  of  its 
occurrence. 

The  symptoms  begin  as  a  mild  conjunctivitis,  with 
lachrymation  and  itching,  burning,  or  irritation  of  the 
conjunctiva,  which  is  more  or  less  reddened  and  injected. 
These  symptoms,  however,  rapidly  increase  in  severity ; 
the  discharge  often  becomes  purulent  in  a  few  hours,  and 
the  inflammation  reaches  its  greatest  intensity  on  the 
second  or  third  day.  The  lids  are  then  cedematous  and 
swollen,  usually  hard  and  tense,  with  a  dusky-red,  glisten- 
ing surface,  and  to  the  touch  are  hot  and  painful.  The 
upper  lid  often  overhangs  the  lower,  and  the  patient  is 
usually  unable  to  open  the  eye.  The  discharge  is  thin, 
creamy,  and  abundant,  and  escapes  between  the  edges  of 
the  lids,  flowing  over  the  cheek,   where  it  may  dry  in 


GONORRHCEAL    CONJUNCTIVITIS.  489 

crusts  and  excoriate  the  skin  ;  later  it  is  thicker  and  less 
abundant. 

On  carefully  separating  the  lids  a  quantity  of  the 
retained  discharge  will  escape,  and  the  conjunctiva  is 
seen  to  be  intensely  red,  swollen,  rough  and  spongy, 
and  often  dotted  with  hemorrhagic  points.  As  the  lids 
are  opened  the  pent-up  secretion  sometimes  escapes  in 
quite  a  jet,  and  the  examiner  should  be  very  careful  to 
keep  his  own  eyes  at  a  safe  distance.  The  swollen 
and  congested  ocular  conjunctiva  is  lifted  up  from 
the  globe  by  the  exudate,  overlaps  the  margin  of  the 
cornea,  and  forms  a  circular  wall  around  it.  The  cornea 
thus  forms  the  bottom  of  a  depression  filled  with  pus, 
and  cannot  be  seen  until  the  latter  is  removed.  A  plastic 
exudate  may  cover  portions  of  the  conjunctiva,  the  re- 
moval of  which  exudate  is  followed  by  hemorrhage. 

Pain  in  the  eye  and  in  the  orbital  region  is  often 
intense.  The  local  temperature  is  increased,  but  general 
fever  is  mild  or  absent.  Systemic  disturbances  are  usu- 
ally limited  to  those  caused  by  the  pain,  anxiety,  and 
mental  distress. 

The  great  danger  lies  in  extension  of  the  inflamma- 
tion to  the  cornea — a  process  that  is  encouraged  by  the 
irritating  effects  of  the  pus  retained  in  contact  with  the 
surface  of  the  cornea,  and  by  the  interference  in  the 
corneal  circulation  resulting  from  the  pressure  produced 
by  the  chemosis  and  the  tensely  swollen,  heavy  lids. 
Cloudiness  of  the  cornea  may  be  present ;  this  cloudi- 
ness may  disappear  under  treatment,  leaving  no  perma- 
nent defects.  Ulceration  of  the  cornea,  however,  is  to  be 
dreaded ;  it  begins  as  superficial  losses  of  tissue,  usually 
near  the  margin,  but  it  may  first  appear  at  the  centre. 
Such  ulceration  may  progress  rapidly  and  destroy  large 
portions  or  all  of  the  cornea,  resulting  in  staphyloma, 
prolapse  of  the  iris,  escape  of  the  entire  contents  of  the 
eye,  or  even  purulent  panophthalmitis.  In  less  severe 
cases  the  ulceration  may  be  arrested  by  prompt  treat- 
ment, and  the  vision  may  be  but  partially  lost.     The 


490      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

duration  of  the  disease  is  from  four  to  twelve  weeks. 
In  favorable  cases,  with  no  involvement  of  the  cornea, 
complete  recovery  occurs  in  five  or  six  weeks,  or  there 
is  left  a  chronic  conjunctivitis  which  disappears  under 
appropriate  treatment. 

Pathology. — There  is  inflammation  of  the  conjunc- 
tiva and  of  the  subconjunctival  tissues.  The  point  of 
special  interest  is  the  presence  and  location  in  the  tissues 
of  the  gonococci  :  they  rapidly  penetrate  to  the  upper 
layers  of  the  subepithelial  tissues,  where  their  presence 
is  soon  followed  by  the  phenomena  of  inflammation. 
Just  where  they  chiefly  proliferate  is  an  undecided  ques- 
tion, but  they  are  most  numerous  in  the  epithelium  and 
in  the  secretion. 

Diagnosis. — The  symptoms  are  usually  so  pronounced 
that  the  diagnosis  is  not  difficult.  Purulent  conjuncti- 
vitis from  other  causes  presents  symptoms  of  the  same 
type,  but  less  severe,  and  the  secretion  does  not  contain 
gonococci.  Treatment  is  the  same.  To  avoid  confusing 
the  two  distinct  types  of  ophthalmic  disease  that  may 
complicate  gonorrhoea,  the  following  table  of  Fournier's 
is  given : 


Gonorrhoea!  Conjunctivitis. 

Essential  cause  is  inoculation  of  the 
conjunctiva  with  gonorrhoeal  pus. 

A  rare  affection. 


May  affect  subjects  not  suffering 
from  gonorrhoea. 

Usually  but  one  eye  involved. 

The  symptoms  are  those  of  the 
gravest  forms  of  purulent  con- 
junctivitis ;  they  affect  the  con- 
junctiva primarily. 

Symptoms  fixed,  not  going  from 
one  eye  to  the  other. 

No  tendency  to  relapse  in  subse- 
quent gonorrhoeas. 


Gonorrhoea/  [Rheumatic) 
Ophthalmia. 

Not  contagious ;  develops  under 
the  influence  of  an  internal  cause, 
the  nature  of  which  is  unknown. 

An  infrequent  complication  of  gon- 
orrhoea. More  common  than  gon- 
orrhoeal conjunctivitis — 14  :  I. 

Only  attacks  patients  already  suffer- 
ing from  gonorrhoea. 

Commonly  both  eyes. 

Symptoms  are  those  of  inflamma- 
tion of  the  membrane  of  Desce- 
met,  of  an  iritis,  or  of  a  mild 
conjunctivitis. 

Symptoms  may  be  mobile,  passing 
from  one  eye  to  the  other. 

Frequent  relapses  in  the  course  of 
subsequent  gonorrhoeas. 


GONORRHCEAL    CONJUNCTIVITIS.  49 1 

Gonorrhceal  {Rheumatic) 
Gonorrheal  Conjunctivitis.  r\.i,i    ,     ■ 

J  Ophthalmia. 

No    coincidence    with     rheumatic  Occurs    with    gonorrhceal   rheuma- 

manifestations.  tism,  rarely  without. 

Prognosis  excessively  grave ;  often  Prognosis  without  gravity, 
loss  of  eye. 

Eye   is  saved   only  by  most   ener-  Expectation,  or  the  simplest  treat- 

getic   treatment.  ment,  sufficient  for  a  cure. 

Gonococci  in  the  discharge.  No  gonococci. 

Treatment. — The  treatment  must  be  prompt  and 
thorough.  A  few  hours'  delay  may  cause  the  loss  of 
the  eye.  The  patient  should  go  to  bed  in  a  darkened 
room,  and  should  have  a  trained  nurse  in  constant  at- 
tendance, to  keep  the  surfaces  cleansed  and  properly 
dressed  and  to  protect  the  sound  eye  from  infection.  At 
least  two  such  nurses,  one  for  day  and  one  for  night,  are 
necessary  during  the  acute  stage.  In  some  cases  it  is 
best  to  protect  the  sound  eye  by  sealing  it  hermetically 
with  a  piece  of  light  rubber  tissue  covered  with  a  thin 
layer  of  cotton  or  gauze,  which,  with  the  rubber,  is  fast- 
ened by  means  of  collodion  to  the  skin  surrounding  the 
orbit.  An  opening  for  ventilation  may  be  left  at  the 
outer  side.  Rubber  plaster  may  be  used  instead  of  col- 
lodion, while  for  those  who  can  obtain  it  promptly 
Buller's  shield,  having  a  watch-glass  centre,  is  the  best 
device. 

In  the  beginning,  if  the  patient  be  strong  and  robust, 
several  ounces  of  blood  may  be  abstracted  from  the  tem- 
ple by  means  of  leeches  or  cups,  and  a  brisk  cathartic 
may  be  administered.  This  treatment  may  be  followed 
for  several  days  by  laxatives  and  a  light  diet.  In  a  less 
vigorous  patient  these  measures  would  be  too  severe, 
since  it  is  very  important  that  the  general  strength  and 
the  recuperative  powers  be  maintained  fully.  In  cachectic 
or  debilitated  subjects  or  in  those  with  poor  hygienic 
surroundings  the  task  of  trying  to  save  the  cornea  is 
exceedingly  difficult. 

The  objects  of  local  treatment  are  ( 1 )  to  keep  the  surfaces 


492      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

clean  and  to  prevent  the  accumulation  of  secretion  beneath 
the  lids  ;  (2)  to  reduce  congestion  by  the  constant  applica- 
tion of  cold ;  (3)  to  relieve  pressure ;  and  (4)  in  all  but 
mild  cases  to  combat  the  process  with  applications  of  anti- 
septic and  astringent  or  caustic  solutions.  The  accumula- 
tion of  pus  about  the  edges  of  the  lids  and  under  them 
should  be  wiped  away  gently  with  lint  or  with  bits  of 
cotton  wrapped  on  the  ends  of  toothpicks.  Such  lint, 
cotton,  and  toothpicks  should  promptly  be  burned.  No 
dressing  of  any  description  should  be  used  a  second 
time.  Safety  for  the  patient's  sound  eye  and  for  the 
eyes  of  the  physician  and  the  attendants  demands  that 
every  piece  of  cloth  or  other  dressing  that  has  once 
come  in  contact  with  the  smallest  particle  of  the  dis- 
charge should    immediately   be  destroyed    by  burning. 

After  the  first  cleansing  further  accumulation  of  pus  be- 
neath the  lids  should  be  prevented  by  frequent  washing 
with  a  3  per  cent,  solution  of  boric  acid  in  distilled  or 
boiled  water.  A  solution  of  bichloride  of  mercury  (1  : 
20,000  to  1  :  5000)  or  permanganate  of  potassium  (1  : 
2000  to  1  :  500)  may  be  used  instead.  The  lids  are 
gently  separated,  and  the  liquid  is  allowed  to  flow  over 
the  surfaces  until  all  secretion  is  removed.  The  solution 
is  best  applied  by  squeezing  it  out  of  pieces  of  cotton  or 
sponge ;  a  bulb-syringe  may  be  used,  but  the  ordinary 
irrigating  syringe  is  liable  to  spatter  and  to  endanger 
the  oth'er  eye.  The  patient's  head  should  be  turned 
slightly  to  the  side  of  the  affected  eye,  to  prevent  any 
possibility  of  the  solution  reaching  the  opposite  side, 
and  a  pus-basin  or  wads  of  cotton  should  be  held  in 
position  to  catch  the  discharge.  This  irrigation  of  the 
inflamed  surfaces  should  be  repeated  every  fifteen  to 
sixty  minutes,  both  day  and  night,  during  the  acute 
stage,  and  less  frequently  as  the  discharge  becomes  less 
abundant.  The  object  is  to  keep  the  surfaces,  and 
especially  the  cornea,  free  from  pus. 

During  the  intervals  between  the  washings  cold  is 
applied  by  means  of  pieces  of  soft  linen,  large  enough  to 


GONORRHCEAL    CONJUNCTIVITIS.  493 

cover  the  eye,  taken  out  of  ice-water  or  from  the  surface 
of  a  block  of  ice  over  which  has  been  laid  a  layer  or  two 
of  gauze.  These  pieces  of  linen  are  removed  and 
burned,  and  are  replaced  by  fresh  ones  every  two 
minutes.  Exceptionally,  too  much  cold  is  applied 
and  produces  a  dulling'  of  the  corneal  lustre,  but  with- 
out indications  of  loss  of  substance.  In  such  cases  cold 
applications  should  be  suspended  at  intervals.  Hot 
applications  should  never  be  made  during  the  acute 
stage.  The  constant  dressing  and  handling  of  the  eye 
must  be  done  with  the  utmost  care  and  gentleness,  and 
should  be  made  to  interfere  as  little  as  possible  with  that 
physiological  rest  which  is  so  greatly  to  be  desired  in 
any  acute  inflammation.  The  fingers  should  not  come 
in  contact  with  the  globe,  or,  if  possible  to  avoid  it,  with 
the  edges  of  the  lids.  Pressure  (of  heavy  dressings,  etc.) 
should  be  prevented.  If  the  upper  lid  is  thick  and  tense 
and  difficult  to  evert,  thus  preventing  proper  cleansing 
of  the  eye  and  producing  pressure  upon  the  cornea,  can- 
thoplasty  should  be  performed  freely.  The  fingers  or  a 
wire  speculum  hold  the  lids  apart  and  thoroughly  stretch 
the  skin  over  the  outer  canthus ;  one  blade  of  a  pair  of 
sharp,  strong  scissors  is  passed  under  the  lid,  and  the 
point  is  carried  to  the  bottom  of  the  cul-de-sac ;  a  single 
sharp  cut,  which  should  be  exactly  horizontal,  divides 
the  tissues  to  the  margin  of  the  orbit.  Pressure  is  thus 
relieved  and  free  irrigation  of  the  eye  is  made  possible. 
If  the  parts  heal  too  rapidly,  it  may  be  necessary  to  re- 
peat the  operation. 

In  mild  cases  frequent  cleansing  and  the  constant 
application  of  cold  may  be  all  the  local  treatment  neces- 
sary. In  most  cases,  however,  when  the  conjunctiva 
becomes  greatly  swollen  and  the  discharge  profuse  and 
purulent,  a  I  or  2  per  cent,  solution  of  nitrate  of  silver 
should  be  used.  If  the  cornea  is  clear,  2  or  3  drops  of 
such  a  solution  may  be  dropped  between  the  lids ;  but  a 
better  method  is  to  evert  the  lids  and  apply  a  2  (occasion- 
ally a  3  or  4)  per  cent,  solution  to  the  conjunctiva  by 


494      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

means  of  a  bit  of  cotton  twisted  on  the  end  of  a  tooth- 
pick. After  a  few  seconds  the  surfaces  may  be  gently- 
wiped  dry  or  washed  with  a  common  salt-solution.  By 
allowing  the  nitrate  solution  to  remain  on  the  conjunctiva 
a  longer  or  shorter  time  the  duration  and  extent  of  the 
caustic  action,  indicated  by  the  whitening  of  the  surfaces, 
can  be  controlled,  and  danger  of  irritating  the  cornea 
by  contact  with  the  fluid  is  avoided.  In  ulceration  of 
the  cornea  the  avoidance  of  such  irritation  is  a  matter 
of  special  importance. 

Following  such  an  application  the  discharge  is  greatly 
lessened,  though  the  swelling  continues,  and  pain  is  tem- 
porarily increased.  If  the  iced  cloths  do  not  relieve  the 
pain,  solutions  of  atropine  or  of  cocaine  may  be  used. 
After  a  few  hours  the  discharge  reappears  and  contains 
fine  shreds  of  the  eschar  resulting  from  the  caustic.  Fre- 
quent washings  and  another  application  of  the  silver- 
solution  are  then  in  order.  In  the  early  stages  of  the 
affection  solutions  of  the  nitrate  should  be  used  but  once 
in  twenty-four  hours ;  later  they  may  be  used  every  six, 
eight,  twelve,  or  twenty-four  hours,  depending  upon  the 
rapidity  with  which  the  conjunctiva  recovers  from  the 
application.  Dr.  Joseph  A.  Andrews  has  well  empha- 
sized the  fact  that  the  caustic  solution  should  not  be 
used  until  the  eschar  produced  by  the  previous  applica- 
tion has  disappeared  entirely.  The  use  of  the  nitrate  of 
silver  solution  should  always  be  preceded  by  a  thorough 
washing  of  the  surfaces,  and  may  be  followed  at  intervals 
of  an  hour  or  two  by  the  free  use  in  the  eye  of  a  pure 
vaseline. 

A  remedy  that  promises  to  replace  nitrate  of  silver 
in  these  cases  is  protargol,  as  it  seems  to  be  equally 
efficient  and  much  less  irritating.  For  application  with 
a  brush  or  cotton,  solutions  varying  in  strength  from 
5  to  30  per  cent,  may  be  used.  At  the  same  time  two 
drops  of  a  2  to  5  per  cent,  solution  may  be  instilled  in 
the  eye  two  or  three  times  a  day. 

The  cornea  should  be  watched  carefully.     If  it  be- 


OPHTHALMIA    NEONATORUM.  495 

comes  cloudy  or  ulcerates  centrally,  a  solution  of  atro- 
pine (gr.  ij  to  %))  should  be  dropped  in  the  eye  often 
enough  to  keep  the  pupil  well  dilated.  If  ulceration  be- 
gins at  the  margin,  sulphate  of  eserine  (gr.  j  to  sj)  should 
be  used  instead  of  atropine,  and  with  sufficient  frequency 
to  keep  the  pupil  tightly  contracted,  thus  lessening  the 
danger  of  prolapse  of  the  iris  in  case  of  perforation.  In 
exceptional  cases,  with  pus  in  the  anterior  chamber  and 
with  bulging  of  the  cornea,  puncture  (paracentesis)  is 
advisable ;  and  occasionally  it  is  necessary  to  relieve  the 
pressure  upon  the  cornea  by  free  incisions  into  the 
chemotic  conjunctiva.  Such  incisions  should  be  made 
after,  never  before,  application  of  the  caustic  solution. 

As  the  inflammatory  symptoms  subside  and  the  dis- 
ease progresses  toward  recovery  the  treatment  is  less 
active,  but  careful  watch  of  the  eye  must  be  maintained 
for  fear  of  a  relapse.  In  the  declining  stage,  if  the  cornea 
is  clouded,  absorption  may  be  hastened  by  the  use,  for 
ten  or  fifteen  minutes  several  times  a  day,  of  hot  fomen- 
tations or  irrigations ;  in  the  intervals  the  use  of  cold 
cloths  is  continued.  When  the  discharge  has  become 
slight  the  cold  cloths  may  be  given  up  and  the  surfaces 
may  be  brushed  lightly  every  day  or  two  with  a  1  per 
cent,  solution  of  nitrate  of  silver  or  of  sulphate  of  zinc. 

Prognosis. — The  prognosis  is  always  grave,  but  it  is 
least  favorable  in  the  cachectic  or  the  feeble  and  in  those 
who  have  had  previous  disease  of  the  eyes.  Noyes  gives 
the  result  in  40  cases  as  follows :  In  10  the  cornea  es- 
caped injury  and  recovery  was  complete;  of  the  other  30 
with  involvement  of  the  cornea,  5  retained  useful  vision, 
9  retained  some  vision,  and  16  lost  all.  vision,  in  the  af- 
fected eye.  The  chronic  (granular)  conjunctivitis  which 
often  results  usually  yields  to  appropriate  treatment. 

OPHTHALMIA  NEONATORUM  (BLENNORRHEA 
NEONATORUM). 

The  term  "  ophthalmia  neonatorum  "  is  applied  to  pur- 
ulent conjunctivitis  appearing  in  children  a  day  or  two, 


496      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

or  occasionally  a  few  weeks,  after  birth.  It  is  much  more 
common  than  gonorrhoeal  conjunctivitis  in  the  adult, 
and  is  therefore  of  greater  importance,  but  it  is  of  interest 
chiefly  to  the  obstetrician  and  the  ophthalmologist.  The 
condition  is  the  result  of  direct  or  indirect  infection  of  the 
child's  eyes  with  secretions  from  the  mother's  vagina. 
This  infection  may  occur  during  birth,  but  in  most  cases 
it  probably  occurs  during  the  first  washing  of  the  child, 
or  from  accidental  contact  with  sponges,  napkins,  hand- 
kerchiefs, etc.  used  by  the  mother.  Indirect  infection  by 
some  means  is  undoubtedly  the  cause  of  the  disease 
when  it  appears  after  a  few  days.  The  source  of  infection  is 
not  necessarily  gonorrhoeal ;  other  pus  or  irritating  secre- 
tions may  produce  in  the  child  a  conjunctivitis  differing 
but  slightly,  if  at  all,  from  that  produced  by  gonorrhoea. 

Symptoms.—  The  symptoms  are  essentially  those  of 
gonorrhoeal  conjunctivitis  in  the  adult;  but  the  disease 
may  be  even  more  acute  in  its  course,  and  loss  of  sight 
is  possibly  more  frequent. 

Prophylaxis. — In  case  the  mother  have  a  suspicious 
vaginal  discharge,  her  vagina  should  be  cleansed  with  an 
antiseptic  solution  before  the  child  is  delivered.  Imme- 
diately after  birth  the  child's  eyes  should  be  washed  thor- 
oughly with  a  3  per  cent,  solution  of  boric  acid,  and  two 
drops  of  a  1  per  cent,  solution  of  nitrate  of  silver  should 
be  instilled  in  each  eye  (Crede's  method).  If  the  result- 
ing inflammation  be  too  severe,  it  may  be  limited  by  the 
application  of  cold.  A  5  per  cent,  solution  of  protar- 
gol  may  be  used  instead  of  the  nitrate  of  silver.  Every 
precaution  should  be  taken  lest  the  child's  eyes  be  in- 
fected later  through  the  careless  use  of  handkerchiefs, 
towels,  etc. 

Treatment. — The  treatment  is  practically  that  of  the 
disease  in  the  adult,  except  that  nitrate  of  silver  and  pro- 
targol  should  be  used  with  greater  caution  and  in  weaker 
solutions  (0.5  per  cent,  of  the  former  and  from  2  to 
5  per  cent,  of  the  latter),  and  be  limited  in  their  appli- 
cation  to   such  cases   as  fail  to  improve  under  the  use 


GONORRHEAL    INFLAMMATION,   ETC.  497 

of  frequent  washing  and  iced  cloths.  It  is  even  more 
important  than  in  the  adult  that  caustic  solutions  should 
be  kept  from  the  cornea.  For  this  reason  protargol  is  a 
safer  remedy  than  silver  nitrate,  and  is  apparently  equally 
effective.  Canthoplasty  is  rarely  required  in  the  infant. 
Cachexia,  debility,  and  lack  of  development  (premature 
birth)  predispose  to  unfavorable  results. 

Many  children  for  a  few  days  after  birth  have  a  mild 
form  of  conjunctivitis  which  gives  the  lids  a  red  and 
sticky  appearance.  These  cases  call  simply  for  occasional 
bathing  in  simple  borax-water  or  alum-water,  and  should 
not  be  confounded  with  the  purulent  form  of  the  disease. 

GONORRHCBAL  INFLAMMATION  OP  THE  REC- 
TUM   AND    THE   MOUTH. 

A  few  well-authenticated  cases  are  reported  in  which 
the  mucous  membrane  of  the  anus,  of  the  rectum,  or  of 
the  mouth  has  been  involved  in  a  gonorrhceal  inflamma- 
tion. Such  cases  are,  however,  so  rare  that  they  may  be 
classed  among  the  curiosities  of  medical  and  surgical 
practice.  The  gonococcus  does  not  readily  invade  these 
membranes,  but  when  the  disease  does  occur  in  these 
localities,  it  is  undoubtedly  due  to  local  infection  with 
gonorrhceal  pus,  and  not,  as  has  been  suggested,  to  met- 
astasis. Infection  may  be  the  result  of  accident  or  un- 
cleanliness.in  those  suffering  from  gonorrhoea,  or  it  may 
be  due  to  unnatural  coitus. 

Occurring  in  the  anus  and  the  rectum,  the  disease  be- 
gins with  itching  and  burning  sensations  which  rapidly 
increase  in  intensity  until,  in  a  few  days,  pain  is  constant 
and  greatly  increased  on  defecation.  The  membranes 
become  intensely  red,  hot,  congested,  and  swollen,  and 
secrete  at  first  a  thin,  creamy  discharge,  which  soon  be- 
comes thicker,  darker,  and  profuse.  The  inflammation 
is  usually  limited  to  the  anus  or  to  the  membrane  below 
the  internal  sphincter.  The  diagnosis  between  gonor- 
rhceal and  other  forms  of  proctitis  will  rest  chiefly  upon 

32 


49^      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

the  discovery  of  gonococci  in  the  discharge  and  upon 
the  history.  In  women  the  cause  may  be  found  in  a 
gonorrhoea  of  the  vagina  or  the  urethra,  the  discharge 
from  which  has  been  allowed  to  run  down  over  the  anus 
and  infect  the  membrane.  When  the  disease  occurs  in 
one  who  has  practised  sodomy  for  some  time,  the  sphinc- 
ters are  relaxed,  the  anal  folds  are  wanting,  and  the  anus 
may  be  more  or  less  funnel-shaped. 

If  limited  to  the  anus,  the  disease  should  be  treated 
simply  with  cleansing  and  astringent  lotions  and  powders, 
and  the  surfaces  should  be  separated  with  soft  dressings, 
the  principles  and  details  of  treatment  being  essentially 
those  recommended  for  balanitis.  Excoriations,  fissures, 
and  superficial  fistulas  may  be  touched  with  solutions  (or 
the  solid  stick)  of  nitrate  of  silver.  If  the  disease  extends 
into  the  rectum,  care  should  be  taken  to  secure  a  regular 
daily  evacuation  from  the  bowel,  and  the  rectum  should 
be  irrigated  thoroughly  once  or  twice  daily  with  a  warm 
saturated  solution  of  boric  acid.  For  this  purpose  the 
rectal  irrigator  devised  by  Dr.  James  P.  Tuttle  is  desirable. 
In  the  declining  stage  some  of  the  astringent  solutions 
recommended  for  this  stage  of  urethral  gonorrhea  may 
be  used.  It  may  be  necessary  to  dilate  the  sphincters 
and  to  apply  a  solution  of  nitrate  of  silver  to  excoriations 
and  superficial  ulcers  that  may  be  present. 

Gonorrhceal  inflammation  of  the  mucous  membrane 
of  the  mouth  has  been  reported  in  very  few  instances, 
the  largest  number  of  cases  being  in  new-born  infants 
undoubtedly  infected  during  birth  by  vaginal  discharges. 
The  symptoms  are  those  of  a  severe  stomatitis.  The 
diagnosis  is  made  from  the  history  and  by  the  finding  of 
gonococci  in  the  discharge.  In  new-born  children  the 
disease  appears  much  earlier  than  do  other  forms  of 
stomatitis.  The  treatment  consists  in  frequent  washing 
of  the  mouth  with  warm  saturated  solutions  of  boric 
acid  (the  addition  of  slippery  elm  or  of  flaxseed  to  the 
solution  is  sometimes  very  grateful),  and  in  the  applica- 
tion to  the  surface  of  astringent  solutions.     Nitrate  of 


GONORRHCEAL    INFLAMMATION,   ETC.  499 

silver  in  strength  varied  to  meet  the  indications  of  each 
case  is  the  best  preparation. 

Gonorrhceal  inflammation  of  the  nose  has  been  men- 
tioned by  several  writers,  but  an  unquestionable  case  has 
not  been  reported. 


STRICTURE   OF  THE  URETHRA. 


Stricture  of  the  urethra  has  been  denned  commonly 
as  an  unnatural  narrowing  or  constriction  of  some  por- 
tion of  the  urethral  canal.  As  the  urethral  walls  are 
usually  in  apposition,  and  the  urethra  is  a  canal  only 
when  distended  with  fluids  or  instruments,  stricture  has 
been  defined  as  a  loss  of  dilatability  of  the  urethra. 
These  definitions  include  a  number  of  conditions,  which, 
for  the  sake  of  clearness,  are  given  brief  mention  before 
beginning  the  consideration  of  the  subject  in  hand — 
namely,  true  organic  stricture. 

The  calibre  of  the  urethra  may  be  narrowed,  even  to 
the  point  of  complete  obstruction,  by  pressure  from  with- 
out of  a  periurethral  abscess,  cyst,  or  other  tumor,  or  of 
an  inflamed  or  hypertrophied  prostate ;  or  by  the  pres- 
ence within  the  urethra  of  polypi  or  other  growths ;  but 
in  these  conditions  the  narrowing  is  secondary  to  other 
diseases,  and,  to  avoid  confusion  of  terms,  should  not  be 
called  "  stricture." 

The  swelling  of  the  mucous  membrane  in  acute  in- 
flammation of  the  urethra  may  diminish  the  size  of  the 
canal  sufficiently  to  interfere  greatly  with  the  passage 
of  urine,  but  this  condition,  unless  complicating  a  pre- 
existing organic  stricture,  or  unless  associated  with  pros- 
tatic disease  or  urethral  spasm,  is  rarely  sufficient  to 
cause  complete  retention,  and,  moreover,  is  transitory. 
The  term  "  inflammatory  stricture,"  which  has  been 
applied  to  this  condition,  is  confusing  and  should  be 
dropped.  It  should  be  remembered,  however,  that  the 
majority  of  strictures,  including  spasmodic  stricture,  are 
complicated  at  times  by  more  or  less  inflammation  or 
congestion. 

500 


STRICTURE    OF   THE    URETHRA.  501 

Spasmodic  stricture  is  a  term  applied  to  the  spas- 
modic contraction  of  the  urethral  muscles  that  frequently 
occurs  during  instrumentation  of  the  urethra,  and  which 
not  uncommonly  results  from  other  local  or  reflex  irrita- 
tion or  from  psychical  causes.  In  the  majority  of 
healthy  urethras  the  passage  of  a  bulbous  bougie  for  the 
first  time  will  induce  a  contraction  of  the  urethal  muscles 
sufficient  to  impede  the  progress  of  the  instrument  for  a 
few  seconds.  Spasmodic  contraction  of  the  compressor 
urethras  and  the  "  cut-off"  muscles,  or  the  failure  to  in- 
hibit such  contraction,  makes  it  impossible  for  some  men 
to  urinate  in  the  presence  of  others.  In  such  a  case  the 
urethra  and  bladder  may  be  entirely  normal,  and  the 
cause  of  the  failure  is  purely  mental,  for  if  the  patient 
withdraw  to  a  private  closet,  or  if  a  catheter  be  passed 
beyond  the  contracted  muscle,  the  urine  flows  freely. 

While  urethral  spasm  may  thus  occur  in  apparently 
healthy  individuals  with  normal  urethras,  its  production 
is  usually  due  to  some  local  or  general  pathological  con- 
dition. Predisposing  causes  are  found  in  a  sensitive  or 
irritable  condition  of  the  nervous  system,  in  any  dis- 
turbed mental  state,  in  cachexia  and  debility,  and  in  a 
rheumatic  or  gouty  diathesis.  It  is  easily  provoked  in 
the  intemperate,  and  especially  in  those  whose  sexual 
hygiene  is  faulty.  In  some  individuals  there  is  a  local 
hyperaesthesia  of  the  urethral  mucous  membrane  for 
which  no  sufficient  cause  is  found,  but  in  whom  intro- 
duction of  a  sound  always  produces  urethral  spasm. 

The  exciting  causes  are  found  in  any  direct  irritation, 
congestion,  or  inflammation  of  the  urethra;  in  the  reflex 
irritation  due  to  disease  of  or  operation  upon  any  por- 
tion of  the  genito-urinary  tract,  rectum,  or  anus ;  in  irri- 
tation reflected  from  more  distant  parts  of  the  body ;  and 
in  psychical  disturbances.  The  use  of  instruments  in 
the  urethra  or  operations  upon  any  portion  of  it  may  be 
followed  by  spasm  of  the  deep  urethra  and  retention  of 
urine.  Such  spasmodic  stricture  may  persist  for  several 
days;     A  similar  condition  frequently  accompanies  the 


502      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

congestion  of  the  deep  urethra  resulting  from  alcoholic 
or  sexual  excesses  or  from  exposure  to  cold.  Occasion- 
ally such  congestion  and  spasm  are  produced  by  the 
internal  use  of  cantharides,  turpentine,  and  other  drugs. 
Reflex  spasm  of  the  deep  urethra  may  follow  operations 
upon,  or  disease  of,  any  portion  of  the  genito-urinary 
tract,  or  may  result  from  inflamed  hemorrhoids  and 
other  sources  of  irritation  in  the  rectum.  It  is  reported 
to  have  followed  operations  upon  more  distant  parts  of 
the  body,  and  to  have  been  produced  by  a  number  of 
other  causes,  including  strongly  concentrated  urine,  ma- 
laria, neuralgia,  abscess  of  the  lumbar  vertebra  (Keyes), 
necrosis  of  the  coccyx  (Emmet),  etc. 

In  most  cases  of  urethral  spasm,  however,  the  cause 
lies  in  a  congested  or  granular  patch  of  mucous  mem- 
brane or  in  an  organic  stricture  situated  in  the  bulbous 
or  bulbo-membranous  portion  of  the  urethra.  Spasmodic 
stricture  may  be  produced  by  local  disease  in  other  por- 
tions of  the  urethra,  if  such  lesions  be  irritated  in  any 
manner.  The  importance  of  a  small  meatus  or  of  a 
stricture  of  large  calibre  in  the  anterior  urethra  as  a 
cause  of  spasm  of  the  deep  urethra  has  unquestionably 
been  over-estimated.  Spasmodic  stricture  due  to  a  con- 
genitally  narrow  meatus  or  to  strictures  of  large  calibre 
in  the  anterior  urethra,  uncomplicated  by  inflammation 
or  other  pathological  changes,  is  certainly  very  rare.  If, 
however,  a  sound  be  used  too  large  for  a  given  meatus, 
the  forcible  stretching  of  the  latter  will  usually  result  in 
the  production  of  spasmodic  stricture. 

Spasmodic  stricture,  which  is  usually  situated  in  the 
membranous  urethra,  is  due  to  the  contraction  of  the 
compressor  urethrae  and  accelerator  urinae  muscles  and 
of  the  voluntary  perineal  muscles  which  make  up  the 
"cut-off"  muscles  of  Cruveilhier;  but  it  occurs  in  less 
pronounced  form  in  the  anterior  urethra  when  the 
unstriped  muscular  fibres  of  the  urethral  wall  contract 
about  a  foreign  body — as  an  instrument — or  about  an 
irritated  area  of  disease. 


STRICTURE    OF   THE    URETHRA.  503 

The  spasm  of  the  urethral  muscles  that  occurs  during 
the  passage  of  a  steel  sound  is  usually  readily  overcome 
by  pressing  the  tip  of  the  sound   quietly  and  steadily 
against  the  contracted  muscles  for  a  few  seconds.    .At 
the  beginning  of  the  membranous  urethra,  especially  in 
a    nervous   or    sensitive   man  whose   urethra  is    being 
explored    for    the    first    time,    the    contraction    of    the 
muscles   may  be  so  firm  and   persistent  that   firm   and 
steady  but   gentle    pressure  of  the    point  of  the   sound 
will   be   resisted   for   several    minutes   before   relaxation 
occurs  and  the  instrument  can  pass.     In  such  a  case  the 
relaxation  is  often  sudden  and  can  be  felt  by  the  hand 
holding  the  sound,  the  tip  of  which  passes  the  obstruc- 
tion with  a  slight  jumping  or  jerking  movement.     As 
a  rule,  the  largest  blunt  steel  sound  that  a  urethra  can 
easily  accommodate  will   overcome  spasm   better  than 
a  smaller  one,  and  will   often    succeed  when   bulbous 
sounds  or  finer  rubber  bougies  fail  to  pass.     Hence,  in 
the  first  examination  of  any  urethra  large  sounds  should 
be  used.     By  beginning  with  smaller  instruments,  and 
especially  with  a  bulbous  sound,  a  diagnosis  of  organic 
stricture   may  be   made  when  there  is   present   nothing 
more  than  urethral  spasm,  which  is  readily  overcome 
by  the  large  blunt  sound. 

In  general,  spasmodic  stricture  occurs  suddenly  and 
is  paroxysmal,  the  stream  of  urine  being  normal  in  size 
except  during  the  urethral  spasm.  If  organic  stricture 
is  also  present — and  this  is  very  frequently  the  case — 
its  calibre  will,  of  course,  determine  the  usual  size  of 
the  stream.  Otis  lays  much  stress  upon  the  occasional 
occurrence  of  spasmodic  stricture  which  may  persist  for 
years  and  in  every  way  simulate  organic  stricture,  even 
to  resisting  the  passage  of  instruments  in  skilled  hands. 
As  every  surgeon  should  make  it  a  rule,  before  beginning 
a  cutting  operation  on  the  deep  urethra,  to  try  to  pass  a 
sound  when  the  patient  is  under  an  anaesthetic  and  the 
muscles  are  relaxed,  these  cases  should  always  be  rec- 
ognized in  time  to  prevent  a  needless  operation.     In  the 


504      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

exceptional  cases  which  simulate  organic  stricture  in 
yielding  only  to  gradual  dilatation,  careful  watching  will 
sooner  or  later  reveal  the  true  condition,  while  the  re- 
moval of  the  cause  of  the  spasm  will  be  followed  by  the 
disappearance  of  the  supposed  stricture. 

The  treatment  of  spasmodic  stricture  lies  in  removing 
the  cause  when  this  can  be  discovered.  Sexual  and 
general  hygiene  and  the  general  health  of  the  patient 
should  be  properly  regulated,  a  bland  urine  should  be 
assured,  and  all  sources  of  direct  or  reflex  irritation, 
such  as  organic  stricture  and  other  lesions  of  the  urethra 
or  of  other  portions  of  the  genito-urinary  tract,  should 
be  removed.  If  retention  occurs,  it  can  usually  be  over- 
come by  allowing  the  patient  to  recline  in  a  hot  bath 
until  the  muscles  relax  and  the  urine  passes  in  the  water. 
If  this  method  fails,  an  opiate  in  full  doses  should  be 
given,  and,  if  necessary,  a  soft  catheter  may  be  passed 
after  filling  the  urethra  with  warm  oil ;  this  operation  is 
rendered  easier  if  done  while  the  patient  reclines  in  the 
bath.  In  exceptional  cases  the  soft  catheter  will  fail 
and  a  metal  instrument  must  be  introduced.  To  avoid 
infection  of  the  bladder  in  catheterization,  the  hand  and 
instruments  must  be  aseptic,  the  meatus  and  glans  disin- 
fected, and  the  anterior  urethra  irrigated  with  an  anti- 
septic solution.  In  extreme  cases  the  production  of  full 
anaesthesia  may  be  required  to  cause  relaxation  of  the 
spasm. 

Congenital  stricture  is  rare  and  is  limited  to  the 
meatus  and  the  quarter  of  an  inch  of  urethra  immedi- 
ately posterior  to  it.  The  size  of  the  normal  meatus 
varies  greatly  in  different  individuals,  and  it  is  impossible 
to  name  a  standard  below  which  a  meatus  should  be 
considered  abnormally  small.  Keyes  says :  "  An  indi- 
vidual with  an  average  sized  penis  and  urethra  whose 
meatus  will  only  take  No.  10  (French)  has  stricture  (con- 
genital) of  the  meatus,  although  he  may  never  suffer 
any  inconvenience  therefrom."  The  opening  may  be 
no  larger  than  a  pin-head,  and  yet  may  cause  the  indi- 


STRICTURE    OF   THE    URETHRA.  505 

vidual  no  inconvenience.  Such  a  condition  is  in  reality 
a  slight  deformity,  and  calls  for  no  treatment.  It  is 
better  to  limit  the  term  "  stricture  "  to  narrowings  that 
are  associated  with  pathological  changes  or  that  interfere 
with  the  normal  functions  of  the  urethra. 

If  the  normal  urethra  be  distended  to  its  greatest  limit 
by  means  of  the  Otis  urethrometer  or  of  large  bulbous 
bougies,  in  the  great  majority  of  cases  the  pendulous  por- 
tion is  found  to  be  less  distensible  at  some  points  than  at 
others.  These  may  be  considered  physiological  points 
of  narrowing  of  the  fully  dilated  urethra,  but  they  are 
often  inappropriately  termed  "  strictures  of  large  calibre," 
and  as  such  are  cut  for  the  purpose  of  relieving  deep 
urethral  spasm  and  other  functional  genito-urinary  dis- 
turbances for  which  the  true  causes  are  not  appar- 
ent. These  points  of  narrowing  vary  greatly  in  size, 
and  are  found  chiefly  within  the  first  three  inches  from 
the  meatus.  As  a  result  of  many  investigations  both 
upon  living  and  dead  bodies,  in  which  these  points 
of  contraction  have  been  found  in  urethras  otherwise 
normal,  the  large  majority  of  modern  surgeons  believe 
them  to  be  physiological.  They  do  not  produce  dis- 
turbances of  the  genito-urinary  functions,  and  they  do 
not  interfere  with  the  normal  distention  of  the  urethra 
during  urination,  or  with  the  passage  of  ordinary  sized 
instruments.  The  belief  is  held  by  a  few  that  the  pendu- 
lous urethra  should  be  a  tube  of  uniform  calibre — or, 
rather,  of  uniform  distensibility — the  diameter  of  which 
should  bear  a  fixed  relation  to  the  circumference  of  the 
flaccid  penis.  Other  parts  of  the  body  are  not  con- 
structed on  such  mathematical  principles,  and  in  the 
face  of  evidence  to  the  contrary  it  is  difficult  to  see  why 
the  penis  should  be  considered  an  exception. 

In  chronic  urethritis  these  points  of  physiological 
narrowing  in  the  pendulous  urethra,  as  well  as  narrow- 
ings of  the  urethra  due  to  chronic  congestion  and  infil- 
tration of  smaller  or  larger  areas  of  the  mucous  membrane 
and  the  submucous  tissues,  have  been  subjects  of  much 


506     syphilis  and  the  venereal  diseases. 

dispute.  Some  practitioners  call  such  narrowings 
"  strictures  of  large  calibre,"  and  operate  upon  them  for 
the  sole  purpose  of  relieving  the  urethral  discharge. 
The  majority  of  surgeons,  however,  do  not  consider  such 
narrowings  strictures,  but  treat  them  as  cases  of  chronic 
urethritis.  There  are  undoubtedly  cases  in  which  the 
question  becomes  a  relative  one,  for  the  majority  of  stric- 
tures are  preceded  by  chronic  urethritis,  with  congestion, 
infiltration,  and  thickening  of  portions  of  the  mucous 
membrane  and  the  submucous  tissues.  Just  when  the 
formation  of  connective  tissue  begins  in  such  areas,  and 
just  when  contraction  of  such  tissue  is  sufficient  to  inter- 
fere with  the  normal  calibre  of  the  urethra,  are  often  dif- 
ficult questions  to  decide.  It  is  best  to  class  these  nar- 
rowings with  stricture  only  when  there  is  periurethral  or 
submucous  deposit  which  has  begun  to  contract  and  to 
diminish  the  lumen  of  the  canal,  producing  a  distinct 
contraction,  or  when  symptoms  of  stricture  (gleet,  fre- 
quency of  urination,  dribbling  of  urine  at  the  close  of 
the  act,  etc.)  are  present.  In  a  doubtful  case,  and  es- 
pecially if  the  point  of  narrowing  is  covered  by  an  in- 
flamed and  thickened  mucous  membrane,  it  is  better  to 
postpone  a  diagnosis  of  stricture  until  the  proper  treat- 
ment for  chronic  urethritis — preferably  the  steel  sound 
— has  been  given  a  faithful  trial. 

The  question  as  to  what  constitutes  the  normal  calibre 
of  any  given  urethra  is  considered  more  fully  in  the  sec- 
tion on  diagnosis,  but,  as  a  rule,  if  the  penis  be  of  average 
size  and  the  urethra  allows  a  No.  24  to  28  (French)  steel 
sound  to  pass  easily,  the  presence  of  stricture  is  improb- 
able. Practitioners  who  find  and  cut  numerous  "  stric- 
tures of  large  calibre  "  in  the  pendulous  urethra  claim 
that,  though  these  narrowings  be  normal,  in  chronic 
urethritis  they  tend  to  increase  the  friction  of  urine  and 
the  irritation  and  inflammation  at  these  points,  and  there- 
fore to  favor  a  deposit  of  plastic  material  and  the  ultimate 
formation  of  a  true  stricture.  It  is  undoubtedly  true 
that  such  a  result  follows  in  a  small  number  of  cases,  and 


ORGANIC  STRICTURE    OF   THE    URETHRA.        507 

that  it  could  be  prevented  by  early  cutting,  followed  by 
the  use  of  the  sound;  but,  on  the  other  hand,  it  should  be 
remembered  that  most  of  these  cases  recover  under  treat- 
ment given  for  chronic  urethritis,  and  that  cutting  opera- 
tions on  the  urethra,  even  in  the  most  skilful  hands,  are 
attended  by  a  mortality  of  from  2  to  5  per  cent.  Further- 
more, such  operations  are  not  infrequently  followed  by 
a  damaged  condition  of  the  urethra  as  bad  as,  or  worse 
than,  that  for  which  the  operation  was  done. 

ORGANIC    STRICTURE   OP    THE  URETHRA. 

Definition. — Organic  stricture  of  the  urethra  may  be 
defined  as  a  pathological  connective-tissue  growth  in  the 
submucous  and  periurethral  tissues,  interfering  with  the 
normal  calibre  and  the  normal  functions  of  the  urethra. 
Dr.  Bryson1  calls  attention  to  the  fact  that  this  connec- 
tive-tissue growth  constituting  stricture  results  from  con- 
tinued pathological  activity  in  the  periurethral  tissues  and 
shows  a  distinct  tendency  to  contract  toward  the  axis  of 
the  canal.  He  proposes  the  name  "  chronic  contracting 
periurethritis "  by  which  to  designate  the  "  stricture 
disease." 

Stricture  is  most  frequently  found  in  men  between  the 
ages  of  twenty  and  forty-five.  It  is  uncommon  in 
women. 

Varieties  of  Stricture. — With  reference  to  form,  stric- 
tures are  classed  as  (1)  linear,  (2)  annular,  and  (3)  tortu- 
ous. 

(1)  Linear  stricture  is  usually  a  cord-like  band,  such  as 
would  be  produced  by  tying  a  cord  about  the  urethra. 

(2)  Amnilar  stricture  is  a  constriction  such  as  would 
be  formed  by  tying  about  the  urethra  a  piece  of  tape  not 
more  than  a  quarter  of  an  inch  wide  (Fig.  32). 

(3)  Tortuous  or  irregular  stricture  includes  every  stric- 
ture that  is  wider  than  an  annular  stricture.  It  may  be 
so  extensive  as  to  include  the  greater  portion  of  the 
pendulous  urethra.     The  calibre  of  this  form  of  stricture 

1  youmal  of  Cutaneous  and  Genito-urinary  Diseases,  Aug.,  1889. 


508      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

usually  varies  in  different  parts,  rendering  the  channel 
tortuous  and  irregular,  hence  the  name  (Fig.  33). 

Aside  from  the  three  forms  of  stricture  described 
above,  obstruction  in  the  urethra  may  exist  in  the  form 
of  a  thin  membrane  or  diaphragm  completely  occluding 
the  canal  but  for  an  opening  situated  centrally  or  eccen- 
trically ;  or  a  crescentic  or  other  shaped  band  or  septum 
may  project  from  a  portion  of  the  urethral  wall ;  or  there 
may  be  a  number  of  fine  bands  crossing  the  urethra 


Fig.  32. — Annular  stricture  (Dittel). 


obliquely  or  transversely,  or  so  situated  as  to  form  flaps 
and  valves.  These  finer  bands,  flaps,  and  valves  are  often 
the  result  of  faulty  instrumentation  of  the  urethra. 

According  to  the  amount  of  contraction  present,  stric- 
tures are  usually  divided  into  strictures  of  small  calibre, 
which  will  only  permit  the  passage  of  an  instrument 
smaller  than  No.  1 5  (French),  and  strictures  of  large  cali- 
bre, which  will  allow  the  passage  of  larger  instruments. 


ORGANIC  STRICTURE    OF   THE    URETHRA. 


509 


The  division  is  an  arbitrary  one,  but  it  is  of  practical 
value,  since,  as  a  rule,  soft  (flexible)  instruments  are  to 
be  preferred  for  all  sizes  below  No.  15.  The  calibre  of 
a  stricture  may  become  so  narrowed  that  it  will  admit  a 


Fig.   33. — Tortuous   stricture,  showing  dilated   follicles,   lacunae,  and   false  passages 

(Dittel). 

fine  probe  with  difficulty,  but  complete  occlusion  of  the 
canal  occurs  only  after  traumatism  or  after  some  other 
outlet  for  the  urine  has  been  provided,  as  in  the  forma- 
tion of  fistulse. 

According  to  their  behavior  with  instruments,  stric- 
tures are  called  simple,  when  readily  dilatable,  irritable, 
when  they  are  very  sensitive  and  easily  inflamed,  or 
resilient,  when  they  are  elastic  and  after  being  dilated 
contract  rapidly  to  their  former,  or  even  to  a  smaller, 
calibre. 

Number  of  Strictures. — Strictures  usually  occur 
singly,  but  a  urethra  may  contain  several  strictures. 
Thompson  has  never  seen  more  than  four  in  a  single 


510      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

urethra.  Other  observers  have  reported  larger  num- 
bers. When  a  number  of  strictures  are  found  in  a  single 
urethra,  careful  examination  will  usually  determine  them 
to  be  irregular  contractions  of  one  stricture.  Multiple 
"  strictures  of  large  calibre  "  in  the  pendulous  urethra  are 
frequently  reported  by  those  who  do  not  recognize  the 
existence  in  this  region  of  points  of  physiological  nar- 
rowing. 

Location  of  Strictures. — The  majority  of  strictures 
of  the  urethra  are  found  in  the  region  which  includes 
the  membranous  and  bulbous  portions.  The  most 
common  seat  is  the  bulbous  urethra.  Stricture  is  fre- 
quently found  within  two  and  a  half  inches  of  the  meatus, 
and  is  occasionally  located  in  deeper  portions  of  the 
pendulous  urethra.  Stricture  does  not  occur  in  the 
prostatic  portion.  The  majority  of  strictures  occurring 
in  the  first  two  and  a  half  inches  of  the  urethra  are  found 
at  the  meatus  or  at  the  posterior  limit  of  the  fossa  na- 
vicularis.  The  reason  for  the  frequency  of  stricture  in 
this  region  and  in  the  bulb  undoubtedly  lies  in  the 
tendency  of  urethritis  to  become  chronic  in  these  parts 
— the  result,  probably,  of  their  great  vascularity  and  de- 
pendent position.  The  membranous  urethra  is  more 
subject  to  traumatism  than  are  the  other  portions,  and 
is  therefore  the  most  frequent  seat  of  stricture  from  this 
cause. 

Otis,  working  on  the  theory  that  the  pendulous  urethra 
should  be  a  tube  of  uniform  dilatability,  finds  the  largest 
number  of  strictures  in  this  portion  of  the  urethra,  placing 
the  majority  within  an  inch  and  a  half  of  the  meatus. 

Etiology. — Stricture  of  the  urethra  is  probably  always 
preceded  by  inflammation  or  traumatism  of  the  mucous 
membrane,  which  is  thus  damaged  sufficiently  to  allow 
the  escape  of  smaller  or  larger  quantities  of  urine  into 
the  submucous  tissues.  Any  form  of  urethritis  may 
be  followed  by  stricture,  but  such  records  as  have  been 
collected  indicate  that  at  least  75  per  cent,  of  all  cases 
of  stricture  owe  their  origin  to  gonorrhoea.     The  more 


ORGANIC  STRICTURE    OF   THE    URETHRA.        5  1 1 

prolonged  the  inflammation,  the  greater  the  probability 
that  stricture  will  follow ;  and  chronic  urethritis  which 
persists  for  months  or  years  results  in  stricture  in  a 
large  proportion  of  cases.  If  during  a  urethritis  the 
inflammation  extends  to  the  periurethral  tissues,  the 
danger  of  stricture  is  greatly  increased.  The  "  break- 
ing "  of  chordee  during  gonorrhoea  is  certain  to  be 
followed  by  stricture  of  the  worst  type,  since  its  origin 
is  traumatic.  Injections  in  gonorrhoea,  when  properly 
used,  are  not  capable  of  producing  stricture,  but  the 
careless  use  of  a  syringe  with  a  long  or  rough  nozzle 
can  easily  damage  the  mucous  membrane  near  the 
meatus,  and  thus  be  the  cause  of  stricture.  This  may 
be  one  of  the  reasons  for  the  frequent  occurrence  of 
stricture  in  this  region.  If  an  injection  (such  as  those 
used  in  attempts  to  abort  gonorrhoea)  be  strong  enough 
to  excite  an  artificial  urethritis  or  to  destroy  a  portion 
of  the  mucous  membrane,  it  will  undoubtedly  be  fol- 
lowed by  stricture.  The  formation  of  stricture  as  a 
result  of  urethral  inflammation  requires  a  number  of 
months  at  least.  Thompson  reported,  of  164  cases  of 
stricture  attributable  to  gonorrhoea,  10  that  appeared 
soon  after  the  attack,  71  within  a  year  after  its  occur- 
rence, 63  in  from  three  to  eight  years,  and  20  in  from 
eight  to  twenty-five  years.  Guyon  and  other  observers 
have  found  that  stricture  appears  from  one  to  ten  or 
fifteen  years  after  gonorrhoea.  When  it  occurs  very 
early,  it  is  probably  due  to  traumatism. 

Traumatic  stricture  is  most  frequently  found  in  the, 
membranous  urethra,  where  it  follows  blows  upon  the 
perineum,  such  as  would  be  produced  by  a  kick  in  this 
region  or  by  a  fall  astride  any  hard  substance  such  as  a 
fence,  a  wheel,  the  tongue  of  a  wagon,  etc.  If  such  an 
injury  be  violent  and  the  injury  to  the  urethra  be  con- 
siderable, it  will  immediately  be  followed  by  hemorrhage, 
and  probably  by  retention  due  to  inflammation  and 
oedema  of  the  urethral  tissues.  When  the  acute  in- 
flammation subsides,  repair  of  the  tissues  begins,  result- 


512      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

ing  in  a  cicatricial  formation  which  ultimately  contracts 
and  produces  stricture.  In  such  cases  the  contraction 
is  comparatively  rapid  and  usually  produces  symptoms 
of  stricture  within  a  few  months,  though  if  the  injury 
be  limited  to  a  portion  of  the  urethral  circumference 
cicatricial  contraction  may  be  slow  and  for  several 
years  may  produce  no  evidence  of  stricture.  If  the 
first  injury  be  slight,  it  may  pass  unnoticed  and  be  for-' 
gotten  until  symptoms  of  stricture  appear  some  years 
afterward. 

In  other  portions  of  the  urethra  traumatic  stricture 
may  result  from  lacerations  of  the  mucous  membrane 
caused  by  the  rough  or  prolonged  use  of  instruments, 
or  by  the  presence  of  other  foreign  bodies,  such  as 
sharp  calculi,  or  from  the  breaking  of  chordee,  or  from 
other  injury  to  the  penis.  Stricture  may  follow  urethral 
chancre  or  other  ulceration,  or  any  process  which 
destroys  the  mucous  membrane  of  the  part.  It  is 
highly  improbable  that  stricture  ever  results  solely  from 
masturbation,  excessive  coition,  or  prolonged  erections, 
although,  after  stricture  has  begun  to  form,  its  further 
development  is  encouraged  by  any  source  of  irritation,  of 
congestion,  or  of  inflammation  of  the  urethra.  Stricture 
also  forms  more  readily  in  tuberculous  or  syphilitic 
individuals  and  in  those  of  a  rheumatic  or  gouty 
diathesis. 

Pathology. — Formation  of  Stricture. — According  to 
Harrison's  conclusions,1  which  have  been  largely  en- 
dorsed by  other  observers,  the  urethral  epithelium  is  so 
damaged  at  one  or  more  points,  as  a  result  of  inflamma- 
tion or  injury,  that  it  permits  the  escape  of  minute 
quantities  of  urine  into  the  submucous  tissues.  To 
prevent  urine  soaking  further  into  the  tissues,  inflam- 
matory exudation  is  excited,  and  barriers  of  plastic 
lymph  are  thrown  out  opposite  the  places  where  leakage 
takes  place.  Such  lymph  ultimately  organizes  to  form 
splints  of  connective  tissue,  evidently  for  the  purpose  of 

1  Lettsomian  Lectures,  1 888. 


ORGANIC  STRICTURE    OF   THE    URETHRA.        5  1 3 

strengthening  the  urethral  wall  and  preventing  further 
leaking  of  the  urine.  But  this  connective  tissue  is 
apparently  influenced  in  its  growth  by  the  presence  of 
minute  quantities  of  urine,  and  differs  from  similar 
tissue  resulting  from  inflammatory  exudates  in  other 
parts  of  the  body  in  that  it  is  denser  and  shows  a  more 
decided  tendency  to  contract.  These  characteristics  are 
most  marked  in  traumatic  stricture,  in  which  the  mucous 
membrane  is  lacerated  and  the  urine  escapes  in  larger 
quantities.  In  these  cases  the  cicatrix  is  dense  and 
contracted,  and  produces  stricture  of  the  worst  type. 
Such  stricture  is  frequently  resilient. 

The  Lesion  in  Stricture. — The  connective-tissue  growth 
constituting  stricture  may  be  limited  to  a  very  narrow 
line  (linear  stricture)  in  the  submucous  tissues,  but  it  is 
usually  formed  in  irregular  masses  in  the  submucous 
and  periurethral  tissues.  It  may  include  large  portions 
of  the  corpus  spongiosum  and  may  obliterate  its  spaces 
(blood-cavities).  The  active  development  of  the  stric- 
ture-formation continues  beneath  the  mucous  membrane 
proper,  which  is  thus  pushed  into  the  urethra  in  front 
of  the  new  growth,  and  may  show  but  little  change  in 
thickness  or  character  even  when  the  underlying  stric- 
ture is  bulky  and  nearly  obliterates  the  urethral  canal, 
though  it  may  be  thinned,  atrophied,  inflamed,  ulcerated, 
or  included  in  a  cicatricial  formation.  In  recent  cases 
the  tissue  forming  the  stricture  is  small  in  amount  and 
is  comparatively  soft  and  yielding.  This  tissue,  how- 
ever, usually  grows  in  density  and  in  amount  and  con- 
tinues to  contract.  In  old  cases,  when  due  to  gonor- 
rhoea, the  urethra  may  be  surrounded  at  the  site  of  the 
stricture  by  irregular  areas  of  knobbed  or  corded,  firm 
masses  that  can  readily  be  felt  by  the  fingers  on  the  out- 
side of  the  penis  as  they  follow  the  course  of  the  ure- 
thra. The  opening  of  the  stricture  is  rarely  situated 
centrally,  but  is  most  frequently  found  near  the  roof,  as 
the  stricture-formation  is  usually  most  abundant  on  the 
floor.     The  opening  may  be  but  slightly  smaller  than 

33 


5 14      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

the  normal  calibre  of  the  urethra,  or  it  may  become  so 
small  as  to  be  almost  impermeable.  Complete  occlusion 
is,  however,  rare  except  after  severe  injury  to  the  ure- 
thra or  after  fistulae  have  formed  to  provide  an  escape 
for  the  urine. 

The  rapidity  with  which  stricture  contracts  and  the 
density  and  extent  of  the  connective  tissue  forming  a 
stricture  are  dependent  upon  several  factors.  Strictures 
due  to  mechanical  or  chemical  violence  (traumatic  stric- 
ture) contract  earlier  and  are  denser  than  those  due  to  in- 
flammation. The  amount  and  shape  of  the  new  formation 
in  traumatic  stricture  depends  largely  upon  the  nature 
and  site  of  the  injury,  and  the  stricture  may  be  linear,  an- 
nular, or  irregular.  Strictures  due  to  gonorrhoea  are  often 
irregular  in  shape  and  lumpy.  Cachexia  and  individual 
tendencies  influence  the  development  of  stricture,  which 
seems  to  form  readily,  extensively,  and  irregularly  in 
the  tuberculous  or  syphilitic  or  in  those  of  gouty  or 
rheumatic  diathesis.  The  habits  of  an  individual  whose 
urethra  contains  a  forming  stricture  also  play  an  import- 
ant part ;  a  faulty  sexual  hygiene,  or  anything  that 
causes  congestion  of  the  urethra,  will  undoubtedly 
hasten  the  formation  of  stricture,  and  tend  to  make  the 
latter  dense  and  contractile. 

Changes  in  the  Urethra. — As  the  stricture  contracts 
and  forms  an  obstruction  to  the  free  outflow  of  urine, 
each  act  of  urination  is  accompanied  by  a  dilatation  of 
the  urethra  immediately  back  of  the  stricture.  The  fre- 
quent stretching  of  this  part  of  the  urethra  is  slight  at 
first,  but  it  gradually  increases  until  the  walls  at  this 
point  lose  their  tone,  become  thinned,  and  a  permanent 
pouch  or  sac  is  formed.  This  pouch  retains  constantly 
a  drop  or  two  of  urine,  which  is  decomposed  by  the 
mucus  and  acts  as  an  irritant  to  the  mucous  membrane. 
Thus  it  happens  that  the  urethral  membrane  immedi- 
ately back  of  a  stricture  is  usually  inflamed  and  produces 
a  gleety  discharge.  The  mouths  of  the  ducts  and  folli- 
cles enlarge,  and  as  the  stricture  contracts  it  increases 


ORGANIC  STRICTURE    OF  THE    URETHRA.        5  1 5 

during  urination  the  pressure  upon  the  urethral  walls 
back  of  it.  The  mucous  membrane  in  this  situation  be- 
comes more  and  more  thinned  and  atrophied,  and  may 
be  pushed  out  between  the  bands  of  muscular  fibres  to 
form  sacculi  or  pockets  in  which  a  few  drops  of  urine 
are  retained  and  decomposed,  thus  adding  to  the  in- 
flammation of  the  urethral  wall,  and  therefore  to  the 
danger  of  ulceration.  Such  sacculi  may  have  their 
origin  in  distended  ducts  or  follicles.  In  severe  cases 
ulcerations  follow,  allowing  of  the  escape  of  a  few  drops 
of  urine  into  the  periurethral  tissues.  There  are  thus 
formed  abscesses  which  open  externally  and  result  in 
urinary  fistula.  Occasionally  some  portion  of  the  thinned 
urethral  wall  gives  way,  and  urine  in  considerable  quan- 
tity escapes  into  the  surrounding  tissues,  producing  the 
serious  accident  known  as  "extravasation  of  urine." 

Resulting  Changes  in  Bladder  and  Kidneys. — Early  in 
stricture  the  congestion  may  extend  to  the  neck  of  the 
bladder,  causing  vesical  irritation  with  frequent  micturi- 
tion ;  or  cystitis  may  result.  Later,  as  the  stricture  con- 
tracts and  produces  greater  obstruction  to  the  outflow 
of  urine,  the  detrusor  urinae  muscle,  as  a  result  of  its 
efforts  to  empty  the  bladder,  becomes  hypertrophied  and 
thickened,  and  bands  of  muscular  tissue  project  into  the 
bladder  in  ridges.  The  contraction  of  the  hypertrophied 
muscles  in  the  bladder-walls  diminishes  the  size  of  the 
bladder-cavity  and  may  eventually  almost  obliterate  it, 
the  muscles  undergoing  fibroid  changes  which  render 
them  incapable  of  distention.  During  the  violent  con- 
tractions of  the  bladder  the  weaker  portions  of  the  wall 
between  the  muscular  ridges  are  pushed  outward  and 
stretched  until  finally  they  form  sacculi  or  pouches 
which  may  have  but  a  small  opening  connecting  them 
with  the  proper  bladder-cavity.  These  sacculi,  having 
no  muscular  fibres  in  their  walls,  cannot  empty  them- 
selves ;  they  therefore  retain  the  decomposing  urine  and 
furnish  a  favorite  site  for  the  formation  of  calculi.  Rarely, 
as  a  result  of  rapid  formation  of  stricture  and  over-disten- 


5 16      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

tion  of  the  bladder,  the  bladder-walls,  instead  of  becom- 
ing hypertrophied,  are  thinned  and  atrophied.  Cystitis 
results  in  most  cases  in  which  decomposing  urine  is 
allowed  to  remain  in  the  bladder. 

The  pressure  of  the  urine,  especially  during  the  act 
of  micturition,  extends  backward  through  the  ureters, 
which  become  dilated  and  hypertrophied,  to  the  pelvis 
and  to  the  calices  of  the  kidneys,  producing  hydro- 
nephrosis. As  a  result  of  inflammation  extending  from 
the  bladder  through  the  ureters  to  the  kidney,  or  more 
frequently  as  the  result  of  microbic  infection,  there  may 
follow  pyelitis,  pyelonephritis,  or,  rarely,  abscess  of  the 
kidney  and  perinephritis.  ■ 

Symptoms  and  Results  of  Stricture. — The  symp- 
toms produced  directly  by  stricture  are  not  so  marked 
as  are  those  resulting  from  secondary  implication  of 
other  parts  of  the  genito- urinary  system.  As  these 
secondary  symptoms  or  results  of  stricture  may  be  first 
both  in  appearance  and  in  importance,  and  as  they  are 
closely  associated  with  such  symptoms  as  may  be  due 
directly  to  the  stricture-growth,  it  is  best  to  consider 
them  together. 

Stricture  of  large  calibre  may  exist  for  months  or  even 
for  years  without  producing  symptoms  of  importance, 
though  when  the  contracture  of  the  urethra  begins  to 
interfere  with  the  normal  function  of  the  canal,  its  pres- 
ence is  usually  manifested  by  a  series  of  characteristic 
disturbances. 

Increased  frequency  of  micturition  is  among  the  earliest 
symptoms  of  stricture,  though  it  may  be  so  slight  at  first 
as  to  pass  unnoticed,  or  may  be  entirely  absent.  As  a 
rule,  the  desire  to  urinate  gradually  becomes  more  fre- 
quent, until  in  old  cases  the  patient  may  find  it  necessary 
to  empty  the  bladder  every  few  minutes.  The  frequency 
with  which  the  bladder  is  evacuated  in  a  day  does  not, 
however,  necessarily  indicate  the  degree  of  contraction  of 
the  stricture,  as  it  may  be  present  in  stricture  of  large 


ORGANIC  STRICTURE    OF   THE    URETHRA.        $1? 

calibre,  but  is  largely  dependent  upon  the  tempera- 
ment of  the  individual  and  upon  the  presence  or  absence 
of  cystitis  and  other  complications.  In  the  beginning  this 
symptom  may  be  due  solely  to  irritation  reflected  from  the 
site  of  the  stricture  to  the  bladder,  and  later  to  irritation 
resulting  from  the  increased  efforts  of  the  bladder  to 
overcome  the  urethral  obstruction  and  to  empty  itself. 
In  many  cases  congestion  of  the  vesical  neck  undoubt- 
edly occurs  early,  and,  as  the  urethral  inflammation  back 
of  the  stricture  increases,  it  extends  at  least  to  the  deep 
urethra  or  to  the  neck  of  the  bladder,  resulting  in  a 
greatly  increased  frequency  of  micturition  due  directly 
to  the  posterior  urethritis  or  cystitis. 

In  tight  stricture  of  long  standing,  as  a  result  of  which 
the  bladder-walls  have  hypertrophied  and  so  reduced 
the  size  of  the  cavity  that  it  will  hold  but  a  small  quan- 
tity of  urine,  the  demands  to  urinate  may  be  so  frequent 
as  to  amount  almost  to  incontinence.  The  same  clinical 
condition  is  found  with  an  atonic  and  constantly  dis- 
tended bladder  which  has  lost  its  power  of  complete 
contraction.  Very  late  in  the  history  of  these  cases  the 
patient  may  be  unable  to  retain  his  urine  for  even  a  short 
period,  and  it  constantly  dribbles  from  the  urethra.  In 
the  first  class  of  cases,  in  which  the  bladder-cavity  is 
nearly  obliterated,  this  condition  constitutes  true  (and 
hopeless)  incontinence,  and  should  carefully  be  distin- 
guished from  the  mere  overflow  of  a  distended  and 
atonic  bladder.  In  the  latter  case  the  use  of  a  catheter 
will  reveal  the  presence  in  the  bladder  of  a  large  quantity 
of  residual  urine.  A  smaller  amount  of  residual  urine 
may  be  found  in  the  majority  of  cases  of  organic  stric- 
ture. In  these  two  forms  of  bladder  disease  result- 
ing from  stricture  the  frequency  of  micturition  and  the 
incontinence  are  worse  during  the  day,  due  to  the  fact 
that  when  the  patient  assumes  the  upright  position  the 
urine  in  the  bladder  produces  pressure  upon  the  vesical 
neck,  or,  in  case  the  latter  is  relaxed,  upon  the  stricture 
and  the  dilated  urethra  back  of  it ;    these  same  symp- 


5 18      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

toms,  when  due  to  prostatic  disease,  are  usually  most  pro- 
nounced at  night. 

Dribbling  after  urination  is  another  early  symptom  of 
stricture.  In  a  normal  urethra  the  close  of  urination  is 
followed  by  a  wave  of  contraction  of  the  muscular  fibres 
surrounding  the  urethra,  expelling  the  last  drops  of  urine 
from  the  canal.  This  action  is  probably  aided  by  a  cor- 
responding wave  of  blood  sent  through  the  corpus  spon- 
giosum by  the  contraction  of  the  accelerator  urinae  mus- 
cle. The  submucous  deposit  in  stricture  prevents,  by 
its  mere  presence,  the  accurate  closure  of  the  urethra, 
and  later,  by  invading  the  muscle-fibres  themselves  and 
by  obliterating  the  meshes  of  the  corpus  spongiosum, 
may  yet  further  interfere  with  the  closure  of  the  canal. 
In  consequence,  the  last  drops  of  urine  are  retained  behind 
the  stricture,  and  do  not  escape  until  later,  by  force  of 
gravity,  when  the  penis  is  dependent. 

Urethral  discharge,  which,  appearing  as  gleet  or  as 
shreds  in  the  urine,  is  present  in  most  cases  of  stricture, 
is  produced  by  the  urethral  inflammation  back  of  the 
constriction.  In  the  forming  stage  of  stricture  the  dis- 
charge may  be  furnished  by  the  inflamed,  granulated,  or 
otherwise  damaged  urethral  membrane  beneath  which 
stricture  is  forming.  Opinions  vary  as  to  the  constancy 
and  importance  of  this  symptom  in  its  relation  to  stric- 
ture. Dr.  White  finds  about  50  per  cent,  of  strictures 
accompanied  by  a  gleety  discharge  from  the  meatus, 
while  a  large  majority  of  all  others  show  shreds  in  the 
urine.  Some  observers  maintain  that  the  presence,  for 
any  considerable  period,  of  a  gleety  discharge  or  of 
shreds  and  pus-corpuscles  in  the  urine  is  sufficient  evi- 
dence of  stricture,  and  advise,  in  such  cases,  operation 
upon  any  points  of  narrowing,  however  slight,  that  can 
be  detected  in  the  urethra.  That  such  a  view  is  extreme 
and  erroneous  is  evident,  since  many  cases  of  chronic  ure- 
thritis that  have  persisted  for  months  or  years  recover 
completely  under  proper  hygienic  management  and  with- 
out local  treatment.     The  amount  of  urethral  discharge 


ORGANIC  STRICTURE    OF  THE    URETHRA.        519 

in  stricture  varies  with  the  general  condition  of  the 
patient  and  his  habits  of  living.  As  in  chronic  ure- 
thritis, congestion  or  irritation  of  the  urethra  from  any 
cause  will  increase  the  amount  of  the  discharge.  In 
stricture  of  large  calibre  the  history  and  symptoms  of 
the  disease  may  differ  in  no  particular  from  those  of 
chronic  urethritis. 

Retention  of  urine  may  occur  early  in  stricture  if  the 
mucous  membrane  covering  it  becomes  inflamed  and 
swollen  as  a  result  of  gonorrhceal  infection,  alcoholic  or 
sexual  excesses,  cold,  or  other  causes  of  urethral  irrita- 
tion and  congestion.  Such  retention,  coming  on  sud- 
denly after  a  debauch,  may  be  the  first  evidence  of  stric- 
ture recognized  by  the  patient.  This  form  of  retention, 
due  chiefly  to  urethral  spasm  and  to  swelling  of  the  mu- 
cous membrane,  rarely  lasts  more  than  a  few  hours,  and 
is  readily  relieved  by  hot  baths,  an  opiate,  or  the  intro- 
duction of  a  soft  catheter.  In  an  unobserving  or  dis- 
sipated patient  other  symptoms  of  stricture  may  pass 
unnoticed  for  months  or  even  for  a  few  years,  and  he  may 
suffer  from  repeated  attacks  of  sudden  retention  before 
applying  for  treatment.  As  the  stricture  contracts  and 
diminishes  the  calibre  of  the  urethra,  less  and  less  swell- 
ing of  the  mucous  membrane  is  required  to  produce 
retention,  which  consequently  is  more  easily  provoked, 
occurs  more  frequently,  is  more  persistent,  and  is  re- 
lieved with  greater  difficulty.  In  old  cases  sudden  re- 
tention may  necessitate  the  performance  of  perineal 
section  under  unfavorable  circumstances. 

The  stream  of  urine  becomes  noticeably  smaller  only 
after  the  calibre  of  the  urethra  has  been  diminished  con- 
siderably, as  in  health  the  size  of  the  stream  is  much  less 
than  the  urethral  calibre  (estimated  by  the  size  of  the 
sound  it  will  readily  admit).  As  the  stricture  contracts, 
and  especially  if  there  be  atony  of  the  vesical  walls,  the 
patient  finds  he  is  unable  to  throw  the  stream  of  urine  as 
far  from  his  body  as  formerly,  and  more  time  is  required 
to    empty  the    bladder.       In    old    and    tight    strictures 


520      SYPHILIS   AND    THE   VENEREAL    DISEASES. 

the  contraction  may  be  so  great  that  the  urine  passes 
in  drops  only.  The  stream  may  be  so  modified  in 
shape  that  it  is  twisted,  forked,  peculiarly  curved,  or 
divided  into  several  small  streams ;  but  as  its  form  de- 
pends chiefly  on  the  shape  of  the  meatus,  and  as  it  varies 
greatly  in  health  and  as  a  result  of  conditions  other  than 
stricture,  these  modifications  are  of  little  importance. 

The  sexual  functions  of  the  urethra  may  be  impaired 
early  in  stricture,  but  usually  they  are  not  disturbed 
until  the  obstruction  is  sufficient  to  prevent  the  forcible 
ejaculation  through  the  urethra  of  the  semen,  which  then 
dribbles  from  the  meatus  after  subsidence  of  the  erection, 
or,  in  case  of  very  tight  stricture,  is  forced  back  into  the 
bladder,  to  be  discharged  with  the  next  flow  of  urine. 
The  patient  consequently  is  sterile.  Ejaculation  may 
be  followed  by  pain  in  the  urethra  just  back  of  the  stric- 
ture, or  in  the  bulb  or  the  perineum,  and  the  semen  may 
be  mixed  with  blood.  If  some  of  the  meshes  of  the  cor- 
pus spongiosum,  and  possibly  of  the  corpora  cavernosa, 
are  occluded  by  the  stricture-growth,  the  free  flow  of 
blood  through  these  bodies  is  prevented,  and  erections 
are  painful  or  are  so  imperfect  as  to  render  the  patient 
impotent.  In  old  cases  sexual  desire  is  diminished  or 
entirely  absent,  but  in  recent  cases  the  slight  inflamma- 
tion back  of  the  stricture  may  serve  to  stimulate  and 
irritate  the  sexual  organs. 

Local  pains  varying  greatly  in  character  occur  at  the 
site  of  the  stricture,  in  the  glans  penis,  testicles,  cord, 
perineum,  rectum,  bladder,  and  even  in  more  remote 
parts  of  the  body.  In  stricture  of  small  calibre  there 
is  usually  some  vesical  tenesmus  during  the  entire  act 
of  urination.  While  many  of  the  pains  are  undoubtedly 
reflex  in  character,  many  of  them  are  due  to  the  presence 
of  posterior  urethritis,  cystitis,  or  to  other  complications 
of  stricture. 

The  urine  usually  contains  some  pus,  and  shreds  com- 
posed of  epithelium  and  pus-cells,  but  it  is  otherwise 
normal  unless  cystitis  be  present,  when  it  has  the  cha- 


ORGANIC  STRICTURE    OF   THE    URETHRA.        52 1 

racteristics  of  urine  in  cystitis  from  other  causes.  Keyes 
reports  several  cases  of  stricture  in  which  hsematuria  was 
the  only  symptom. 

Constitutional  symptoms  are  not  directly  produced  by 
stricture  until  late  in  the  disease,  when  the  almost  con- 
stant, painful  attempts  to  force  urine  through  the  narrow 
opening  may  allow  the  individual  no  rest,  and  may  re- 
sult in  complete  exhaustion,  and,  if  unrelieved,  in  death. 
Stricture  rarely  reaches  this  stage,  however,  without  pro- 
ducing cystitis  and  other  results  and  complications  of 
stricture ;  these  secondary  disorders  present  their  own 
characteristic  symptoms  and  may  result  fatally.  Among 
the  chief  complications  and  results  of  stricture  are  inflam- 
matory and  other  disorders  of  the  bladder,  ureters,  and 
kidneys  ;  urinary  calculus  ;  epididymitis  ;  prostatitis  ; 
perineal  abscess ;  urinary  extravasation  and  fistula ; 
hemorrhoids  (from  pressure  on  the  veins  during  strain- 
ing efforts  to  empty  the  bladder) ;  and  disturbance  or 
obliteration  of  the  sexual  functions. 

Mental  disturbance,  as  in  other  diseases  of  the  genito- 
urinary organs,  is  often  extreme  and  difficult  to  over- 
come. Sexual  hypochondriacs  who  are  suffering  from 
ill-defined  pains  and  sensations  or  from  other  functional 
disturbances  due  to  faulty  sexual  hygiene  not  infre- 
quently imagine  themselves  the  subjects  of  stricture, 
and  are  often  reluctant  to  accept  any  other  explanation 
of  their  sensations  or  fancied  disorder. 

Fistula  and  extravasation  are  immediate  results  of 
severe  forms  of  stricture.  When  ulceration  occurs  in 
some  portion  of  the  urethra — usually  one  of  the  sacculi 
or  distended  follicles — back  of  a  stricture,  and  a  few  drops 
of  urine  escape  into  the  surrounding  tissues,  abscess  fol- 
lows. Such  an  abscess  may  open  again  into  the  urethra 
and  produce  an  internal  blind  fistula ;  but  it  usually 
opens  externally,  and,  retaining  its  connection  with  the 
urethra,  produces  urinary  fistula.  A  blind  internal  fis- 
tula may  persist  as  such  for  some  time,  and  may  be  felt 
as  a  hard  lump  in  the  periurethral  tissue,  but  it  usually 


522      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

inflames  and  fills  with  pus,  which  eventually  finds  an 
external  outlet.  Instead  of  forming  a  single  fistula,  pus 
in  the  periurethral  tissues  may  burrow  slowly  in  several 
directions  and  discharge  through  a  number  of  external 
openings  in  the  perineum,  scrotum,  body  of  the  penis, 
thighs,  groins,  or  nates.  Civiale  reported  such  a  case  in 
which  the  urine  afterward  escaped  through  fifty-two  ex- 
ternal openings.  Usually,  however,  one  fistula  forms  at 
a  time  and  serves  as  an  outlet  for  the  urine.  The  walls 
of  such  a  fistula  are  soft  at  first,  but,  influenced  by 
contact  with  urine,  they  gradually  undergo  changes 
similar  to  those  in  stricture-formation,  become  hard  and 
callous,  and  contract  until  the  channel  becomes  too 
small  to  allow  the  escape  of  urine.  A  new  abscess 
forms,  and  terminates  in  a  new  fistula  which  pursues  a 
career  similar  to  the  one  preceding,  and  the  process  may 
thus  be  continued  indefinitely.  Instead  of  opening  on 
the  surface,  a  fistula  may  find  an  exit  in  the  rectum. 

If  a  sufficient  portion  of  the  urethral  mucous  mem- 
brane back  of  a  stricture  is  destroyed  or  gives  way  at 
one  time  to  allow  a  large  quantity  of  urine  to  escape 
into  the  surrounding  tissues,  extravasation  of  urine  fol- 
lows. This  unusual  and  serious  complication  of  stric- 
ture is  described  by  Keyes  as  follows  : 

"  In  infiltration  the  urine  may  take  any  one  of  five 
directions  : 

"  I.  It  may,  when  small  in  quantity,  get  out  of  the 
urethra,  but  not  penetrate  Buck's  fascia,  in  which  case  it 
may  long  remain  confined  to  one  spot  in  the  perineum 
as  a  hard  rounded  swelling,  like  the  blind  internal  fistula 
already  described. 

"  2.  It  may  find  its  way  rapidly  through  the  meshes 
of  the  corpus  spongiosum,  and  cause  gangrene  of  that 
body,  with  sloughing  of  the  glans  penis,  preceded  by 
coldness  and  the  appearance  of  a  black  spot  upon  the 
glans. 

"  3.  It  may  burrow  inside  of  Buck's  fascia,  but  out- 
side of  the  corpus  spongiosum,  forming  a  fistula  opening 


ORGANIC  STRICTURE    OF  THE    URETHRA.        523 

behind  the  glans  penis  near  its  root,  a  hard  ridge  mark- 
ing the  course  of  the  fistula  within  Buck's  fascia. 

"  4.  It  may  escape  behind  the  triangular  ligament  into 
the  cavity  of  the  pelvis. 

"5.  It  may  escape  outside  of  the  common  fascia  of 
the  penis,  in  front  of  the  triangular  ligament,  in  which 
case  it  rapidly  distends  the  perineum,  the  scrotum,  and 
the  connective  subcutaneous  tissue  of  the  penis,  and 
mounts  up  over  the  abdomen,  and  may  also,  more  rarely, 
perforate  the  deeper  layer  of  the  superficial  perineal 
fascia,  and  descend  upon  the  thighs. 

"  When  extensive  infiltration  of  this  sort  occurs,  all 
the  parts  affected  becomes  cedematous  ;  gases  form  in 
the  connective  tissue,  causing  emphysema  and  making 
the  tissues  crackle  when  pressed  by  the  finger.  Dark 
spots  soon  appear,  indicating  gangrene,  and  extensive 
portions  of  tissue  may  slough  unless  relief  be  promptly 
afforded. 

"  The  constitutional  symptoms  are  those  of  shock.  A 
chill  usually  occurs,  followed  by  great  depression,  a  cold 
clammy  skin,  feeble,  quick,  irregular  pulse,  hurried  res- 
piration, furred  tongue,  complete  anorexia,  symptoms  of 
septicaemia,  and  death. 

"  When  urine  escapes  behind  the  triangular  ligament 
— which  it  does  more  rarely — it  infiltrates  deeply  around 
the  prostate  and  rectum  well  back  in  the  perineum, 
around  the  bladder  and  up  behind  the  pubes,  forming 
abscesses  in  the  cellular  tissue  of  the  hypogastrium,  or 
perhaps  deep  pelvic  abscesses." 

Keyes  reports  his  own  experiments  and  quotes  those 
of  Mengel  to  show  that  normal  urine  injected  in  small 
quantities  into  healthy  tissues  is  absorbed  without  injur- 
ing them,  and  believes  that  if  urine  is  evacuated  by 
operation  as  soon  as  it  has  extravasated,  serious  gan- 
grene may  often  be  averted.  If  the  urine  be  decom- 
posed before  its  escape,  as  is  often  the  case,  or  if  infec- 
tious matter  from  the  urethra  be  carried  into  the  tissues 
with  the  urine,  gangrene  is  certain  to  follow. 


524      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

In  very  rare  instances  some  portion  of  the  bladder, 
instead  of  the  urethra,  may  rupture.  This  accident 
is  followed  by  an  extravasation  of  urine  that  almost 
invariably  terminates  fatally. 

Fistula  and  extravasation  occur  only  in  old  and 
neglected  cases  of  stricture,  and  are  almost  never  found 
outside  of  dispensary  and  hospital  practice. 

Instrumentation  of  the  Urethra. 

Before  attempting  the  use  of  instruments  in  the  ure- 
thra, the  student  should  become  thoroughly  familiar 
with  the  anatomy  of  the  urethra  and  the  perineum  and 
with  the  landmarks  of  these  req-ions.  The  followine 
characteristics  of  the  urethra  should  also  be  borne  in 
mind  : 

The  meatus,  as  a  rule,  is  the  narrowest  point  in  a  nor- 
mal urethra,  while  the  membranous  portion  is  nearly  as 
narrow.  In  addition  to  these  two  points  of  decided  nar- 
rowing in  the  urethra,  the  pendulous  portion  may  con- 
tain one  or  more  points  of  slight  constriction,  usually 
situated  in  the  second  or  third  inch  from  the  meatus, 
which  points  are  recognized  only  when  the  urethra  is 
fully  dilated.  The  urethra  also  contains  three  decided 
enlargements.  The  first  is  the  fossa  naviculars,  in  the 
roof  of  which,  about  half  an  inch  from  the  meatus,  is 
a  mucous  flap  forming  the  lacuna  magna,  which  often 
catches  the  points  of  fine  instruments  that  have  been 
improperly  directed,  in  this  region,  to  the  upper  wall. 
The  second  enlargement  is  in  the  bulb,  which,  of  all  por- 
tions of  the  urethra,  is  the  most  distensible  and  elastic, 
and  therefore  most  liable  to  damage  from  the  unskilful 
use  of  steel  instruments.  The  third  enlargement  is  in  the 
prostatic  portion  (Fig.  34). 

The  pendulous  urethra  is  freely  movable,  and  its  curv- 
ature depends  on  the  position  of  the  penis,  but  the 
portion  of  the  urethra  extending  from  a  little  in  front 
of  the  triangular  ligament  to  the  neck  of  the  bladder 
has  normally  a  fixed  curve.     This  portion  of  the  ure- 


ORGANIC  STRICTURE    OF   THE    URETHRA.        $2$ 

thra,  and  especially  its  floor,  is  not  wholly  immovable, 
and  usually  the  curve  may  be  obliterated  by  the  forci- 


ble 34.— The  prostatic   (a),  membranous  (6),  and  spongy  portions  (V)  of  the  normal 
urethra  (Thompson). 

ble  introduction  of  straight  instruments.  Such  a  pro- 
cedure is  painful,  and  is  usually  attended  by  danger 
of  rupturing  the  urethra.  It  is  of  great  importance, 
therefore,  that  all  inflexible  instruments  intended  for 
use  in  the  deep  urethra  should  be  made  with  a  curve 
corresponding  closely  with  the  fixed  (subpubic)  curve  of 
this  portion  of  the  urethra.  In  the  majority  of  cases 
this  curve  approximates  an  arc  of  a  circle  three  and  one- 
fourth  inches  in  diameter,  the  cord  of  this  arc  being  two 
and  three-fourths  inches  long.  For  general  use  an  in- 
strument having  a  slightly  shorter  curve  than  this  is  the 
most  satisfactory.     In  old  men  and  in  those  in  whom 


Fig.  35. — Van  Buren's  sound. 

the  prostate  is  enlarged  or  the  bladder  is  distended  the 
curve  may  be  a  little  longer  than  the  one  described  above. 
Guyon  called  attention  to  the  fact  that  the  fixed  curve 
is  found  in  the  roof  only  of  the  urethra,  since  the  floor 
is  elastic,  extensible,  and  soft,  yields  readily  before  in- 
struments, which  it  therefore  cannot  support  or  guide, 
is  lacerated  or  ruptured  with  comparative  ease,  and  is 


526      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

less  regular  in  formation  than  the  upper  wall.  The 
latter  is  shorter,  less  movable,  more  regular  and  con- 
stant in  its  curve,  smoother  and  firmer,  less  easily  dam- 
aged, less  vascular,  and  less  intimately  connected  with 
important  structures  than  the  lower  wall.  The  prac- 
tical deduction  is  obvious :  in  passing  instruments 
through  the  urethra,  after  the  fossa  navicularis  is 
passed  the  point  should  be  kept  closely  against  the 
upper  wall. 

Catlieterism  or  Sounding  of  the  Uretlira. — The  steel 
sound  plays  a  most  important  part  in  the  treatment 
of  urethral  disease,  and  the  ability  to  introduce  it 
properly  and  skilfully  is  one  of  the  first  requirements. 
The  requisite  skill  cannot  be  acquired  without  practice, 
and  the  student  should  avail  himself  of  every  oppor- 
tunity for  passing  the  sound  or  the  catheter,  both  in 
dead  and  in  living  subjects.  No  amount  of  experience 
and  practice,  however,  will  justify  the  rough  or  forcible 
passage  of  a  sound  or  a  catheter;  the  operation  should 
invariably  be  performed  with  the  greatest  gentleness  and 
patience.  The  beginner  should  make  it  a  rule  never  to 
use  any  force.  It  is  always  best  to  know  how  to  pass 
the  sound  with  either  hand,  but  in  the  following  de- 
scription, as  a  matter  of  convenience,  the  use  of  the  right 
hand  is  implied : 

The  patient,  with  his  thighs  separated,  should  lie  on 
his  back  on  a  firm  table  or  couch.  He  should  be  made 
as  comfortable  as  possible,  both  physically  and  mentally, 
in  order  to  secure  complete  relaxation  of  all  the  muscles. 
To  this  end  his  fears  should  be  removed  by  assuring  him 
that  if  the  instrumentation  proves  painful  it  will  be  stopped 
at  once.  The  surgeon,  standing  at  the  patient's  left,  gently 
holds  the  penis  just  back  of  the  corona  with  the  left  hand, 
while  in  the  right  hand  he  holds  the  sound,  which  has 
been  properly  cleaned,  warmed,  and  anointed.  With  the 
sound  held  lightly,  the  shaft  parallel  with  the  patient's 
groin  and  near  the  skin,  and  with  the  handle  well  de- 
pressed (Fig.  36),  the  tip  of  the  instrument  is  inserted 


ORGANIC  STRICTURE    OF   THE    URETHRA. 


527 


in  the  meatus,  and  the  penis  is  gently  slipped  up  over 
the  sound,  which  may  be  allowed  to  drop  into  the  ure- 


Fig.  36. — Sounding  of  the  urethra. 


thra  by  its  own  weight.     The  penis   should  gently  be 
put  on  the  stretch  to  efface  the  folds  of  the  urethral 


Fig.  37. — Sounding  of  the  urethra. 


mucous  membrane  and  to  enable  the  point  of  the  sound 
to  gravitate  as  far  as  possible  toward  the  bulb.     With 


528      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

the  left  hand  still  holding  the  penis,  the  handle  of  the 
instrument  is  steadily  carried  over  the  surface  of  the 
abdomen  to  the  exact  median  line  of  the  body  (Fig.  37). 
Without  elevating  the  handle  of  the  sound,  the  latter  is 
then  gently  pushed  toward  the  feet  of  the  patient,  while 
the  left  hand  gathers  up  the  scrotum,  testicles,  and  penis 
and  makes  slight  upward  traction  upon  them.  The  point 
of  the  sound  should  be  followed  closely  throughout  by 
the  little  finger  of  the  left  hand,  and  when  the  point  has 
passed  to  the  perineum  and  the  curve  of  the  instrument 
can  be  felt  back  of  the  scrotum,  the  penis  and  the  tes- 


Fig.  3S. — Sounding  of  the  urethra. 

tides  are  dropped  and  the  fingers  of  the  left  hand  are 
placed  on  the  perineum,  where  they  give  support  to  the 
lower  wall  of  the  urethra  and  keep  the  point  of  the  in- 
strument well  against  the  upper  wall.  Up  to  this  time 
the  handle  of  the  sound  has  been  held  constantly  close 
to  the  abdominal  wall.  The  handle  should  now  be 
lifted  and  gently  carried  toward  the  feet,  thus  describ- 
ing an  arc  of  a  circle  exactly  in  the  median  line  of  the 
body.  When  the  handle  of  the  sound  has  reached  and 
passed  the  perpendicular  (Fig.  38),  the  left  hand  leaves 
the  perineum   and   supports   the   handle   of  the   sound, 


ORGANIC  STRICTURE    OF   THE    URETHRA. 


529 


while  the  right  hand  presses  upon  the  pubes  and  re- 
laxes the  triangular  ligament,  allowing  the  sound  by- 
its  own  weight  to  slip  through  the  membranous  and 
prostatic  portions  of  the  urethra  into  the  bladder  (Fig. 
39).  That  the  sound  has  entered  the  bladder  may  be 
demonstrated  by  partially  rotating  the  handle,  showing 
that  the  tip  of  the  instrument  is  free. 


Fig.  39. — Sounding  of  the  urethra. 


To  remove  the  sound  the  handle  is  carried  through 
motions  exactly  the  reverse  of  those  pursued  during  its 
introduction.     Neither  force  nor  traction  is  necessary. 

Force  is  required  for  the  introduction  of  a  sound  in 
exceptional  cases  only,  and  should  never  be  used  by  any 
but  the  expert.  The  sound  should  be  held  lightly  be- 
tween the  tips  of  the  thumb  and  the  fingers,  as  a  firmer 
grasp  would  interfere  with  the  sense  of  touch,  which  is 
of  great  importance,  and  would  increase  the  danger  of 
unconsciously  using  force.  It  should  never  be  forgotten 
that  the  sound  is  a  lever  of  the  first  class,  the  tip  form- 
ing its  short  and  the  handle  its  long  arm,  and  that  the 
pressure  produced  by  the  point  upon  the  urethral'  wall 
is  many  times  greater  than  that  exerted  by  the  hand  of 
the  operator  upon  the  handle.    Even  in  a  normal  urethra 

34 


530      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

the  progress  of  the  sound  may  be  arrested  by  urethral 
spasm,  which  occurs  most  frequently  at  the  beginning 
of  the  membranous  urethra.  The  gripping  of  the  sound 
by  the  muscle-fibres  produces  a  sensation  readily  recog- 
nized by  the  experienced  hand  holding  the  instrument. 
If  the  sound  be  held  quietly  against  the  contracted  mus- 
cles, they  soon  relax  and  allow  the  instrument  to  pass. 
Coaxing  rather  than  forcing  is  the  rule  at  all  times  when 
using  an  instrument  in  the  urethra. 

The  tip  of  the  sound  should  always  be  kept  steadily 
in  the  median  line,  and  all  irregular,  jerking,  or  wab- 
bling movements  should  be  avoided,  as  these  produce 
unnecessary  motions  of  the  tip  in  the  urethra,  and  the 
resulting  disturbance  of  the  urethral  walls  is  the  most 
frequent  cause  of  pain  in  this  operation.  A  support  for 
the  surgeon's  elbow  is  usually  serviceable. 

Beginners  experience  the  most  difficulty  when  the  tip 
of  the  sound  is  passing  from  the  large,  distensible,  and 
movable  bulbous  urethra  to  the  narrower  membranous 
portion.  If  the  handle  be  raised  from  the  abdomen  too 
soon,  the  tip  catches  above  in  the  subpubic  ligament ; 
while  if  the  tip  is  not  held  well  up  against  the  upper  wall 
by  the  fingers  on  the  perineum,  it  may  bury  itself  in  the 
loose  and  movable  floor  below  the  orifice.  Figure  40 
shows  the  bulbous  urethra  greatly  distended  by  the  tip 
of  a  sound  that  has  been  allowed  to  fall  and  turn  over. 
When  the  tip  of  the  sound  is  arrested  at  this  point,  the 
curve  of  the  instrument  bulges  out  in  the  perineum  as  the 
shaft  is  depressed  between  the  thighs,  and  if  the  handle 
be  released,  it  springs  back  toward  the  perpendicular. 
In  such  a  case  the  sound  should  be  withdrawn  an  inch 
or  two  and  reintroduced,  care  being  taken  not  to  raise  the 
handle  too  soon  and  to  keep  the  tip  against  the  upper 
wall.  A  few  gentle  manoeuvres  should  succeed  in  pass- 
ing the  instrument  into  the  bladder,  unless  there  be  stric- 
ture or  unless  the  sound  is  too  large  for  the  urethra. 

While  decided  pain  should  not  be  produced  by  the 
passage  of  a  sound  or  a  catheter  as  described  above, 


ORGANIC  STRICTURE    OF  THE    URETHRA. 


531 


even  a  normal  urethra  shows  some  resentment  at  the 
introduction  of  a  foreign  body.  Slight  pricking,  sting- 
ing, or  tickling  sensations  are  usually  felt  by  the  patient 
as  the  tip  of  the  sound  comes  in  contact  with  the  mucous 
membrane,  and  as  the  instrument  dilates  the  membranous 
and  prostatic  portions  the  desire  to  urinate  may  become 


^-     \ 


Fig.  40. — Relative  positions  of  triangular  ligament  and  bulb  of  urethra  (diagram- 
matic, from  Culver  and  Hayden). 


so  strong  that  the  patient  declares  he  cannot  retain  his 
urine  another  moment.  In  sensitive  patients  the  opera- 
tion may  produce  nausea  or  even  complete  syncope. 
These  disturbances  are  usually  most  marked  in  a  young 
man  having  his  urethra  explored  for  the  first  time,  since 
the  sensitiveness  of  the  urethral  mucous  membrane  is 
rapidly  lessened  as  a  result  of  repeated  instrumentation. 
The  first  micturition  following  the  use  of  an  instrument 
in  the  urethra  is  usually  attended  by  some  smarting  or 
burning.  Urethral  (urinary)  fever,  prostatitis,  or  epididy- 
mitis occasionally  results  even  when  every  precaution 
has  been  taken ;  but  these  results  are  frequently  due 
to  forcible  or  careless  instrumentation   of  the  urethra, 


532      SYPHILIS  AND    THE  VENEREAL   DISEASES, 

or  to  the  use  of  instruments  that  are  not  clean  and 
aseptic. 

When  possible,  instrumentation  of  the  urethra  should 
be  preceded  for  several  days  by  a  course  of  boric  acid 
or  salol  (5-10  grains),  or  urotropin  (3-8  grains)  four 
times  a  day.  If  the  urine  contains  pus,  such  treatment 
should  be  continued,  if  possible,  until  the  urine  is  clear, 
and  is  thus  rendered  aseptic  or  even  antiseptic.  Before 
the  passage  of  an  instrument  the  patient  empties  his 
bladder,  and  as  he  does  so  he  suddenly  stops  the  stream 
once  or  twice  by  closing  the  lips  of  the  meatus  between 
his  thumb  and  finger.  In  this  way  the  urethra  is  dis- 
tended and  its  folds  washed  out.  The  glans  and  meatus 
are  then  wiped  with  a  5  per  cent,  solution  of  carbolic 
acid,  or  a  1  :  1000  solution  of  bichloride.  This  is  suffi- 
cient preparation  for  ordinary  examination  of  the  ure- 
thra; but  if  the  urine  contains  pus,  or  if  the  urethra  is  to 
be  cut  or  otherwise  injured,  the  urethra  and  bladder 
should  first  be  irrigated  with  a  warm  solution  of  boric 
acid,  or  other  mild  antiseptic.  Complete  asepsis  of  the 
urethra  is  possible  in  exceptional  cases  only.  Gentle 
and  skilful  manipulation  of  instruments  is  of  more  value 
in  preventing  infection  than  are  over-energetic  irrigations 
with  antiseptics  strong  enough  to  damage  the  mucous 
membrane  of  the  urethra.  Steel  instruments  should 
always  be  aseptic.  Flexible  instruments  and  the  ope- 
rator's hands  should  always  be  clean,  and  in  operative 
cases  aseptic.  As  a  rule  instruments  should  be  warmed 
before  use  in  the  urethra.  This  precaution  renders  their 
introduction  less  irritating  to  the  mucous  membrane,  and 
the  production  of  spasm  less  frequent.  In  the  absence 
of  warm  water  or  a  flame,  steel  instruments  may  be 
warmed  by  rapidly  rubbing  them  with  a  towel  held  in 
the  hand. 

Lubrication  of  instruments  previous  to  their  introduc- 
tion is  usually  accomplished  with  vaseline,  cosmoline,  or 
albolene,  as  these  articles  do  not  become  rancid  and  are 
easily  sterilized  by  heat ;    I    or  2  per  cent,   of  carbolic 


ORGANIC  STRICTURE    OF   THE    URETHRA.        533 

acid  may  be  added  to  any  of  these.  Sweet  oil  is  a  good 
lubricant.  The  fats  and  oils,  however,  increase  the 
difficulty  of  cleaning  the  instruments,  and  coat  the  walls 
of  the  urethra,  so  that  in  endoscopic  examinations,  or 
when  it  is  desired  to  make  applications  to  the  mucous 
membrane,  other  lubricants  are  necessary.  Glycerine 
answers  the  purpose  very  well,  but  is  often  irritating. 
The  following  jelly,  when  well  made,  answers  every 
purpose  : 

1^  Tragacanth.,  2 ; 

Glycerin.,  5  ; 

Acid,  carbolic,  1  ; 

Aq.  destill.,  q.  s.  ad  100.— M. 

The  tragacanth  must  be  soaked  in  a  part  of  the  water 
for  ten  or  twelve  hours  and  triturated  to  a  homogeneous 
mass  before  adding  the  other  ingredients. 

Instruments. — Of  all  the  instruments  used  in  the  treat- 
ment of  stricture,  the  steel  sound  is  the  most  important. 
Steel  sounds  for  use  in  the  deep  urethra  measure  about 
nine  inches  from  the  tip  to  the  junction  of  the  shaft  and 
the  handle,  and  are  blunt  or  conical.  Blunt  sounds  are 
of  a  uniform  diameter  throughout  their  entire  length  ; 
conical  sounds  are  several  sizes  (from  3  to  7  sizes  French) 
smaller  at  the  tip  than  in  the  shaft,  the  conicity  extend- 
ing from  the  tip  to  about  the  beginning  of  the  curve. 
The  blunt  sound  is  chiefly  valuable  for  exploration  and 
for  the  treatment  of  urethral  lesions  other  than  stricture. 
The  slightly  conical  sound  is  the  most  generally  useful 
and  the  most  economical,  as  fewer  sizes  are  needed. 
All  steel  sounds  for  use  in  the  deep  urethra  should  pos- 
sess the  curve  already  described,  should  be  polished  per- 
fectly smooth,  should  be  nickle-plated,  and  should  have 
the  size  of  the  shaft  plainly  stamped  on  the  handle. 

The  scale  used  for  determining  the  size  of  urethral  in- 
struments varies  greatly  in  different  countries  and,  unfor- 
tunately, with  different  instrument-makers.  The  French 
scale  furnishes  a  definitely  fixed  standard,  and  is  that  to 


534      SYPHILIS  AND    THE   VENEREAL   DISEASES. 


which  all  numbers  in  these  pages  refer.  By  this  scale 
the  number  on  a  sound  indicates  its  circumference  in 
millimeters.  No.  I  is  one  millimeter,  No.  2  two  milli- 
meters, and  so  on  through  the  entire  scale.  The  divisions 
on  this  scale  are  so  small  that  it  is 
rarely  necessary  to  have  sounds  repre- 
senting all  the  numbers,  especially  in 
conical  and  in  flexible  instruments. 
In  making  a  set  every  other  number 
may  be  omitted,  so  that  eleven  conical 
steel  sounds  ranging  from  15  to  35  in 
sizes  (the  tip  of  each  being  three  or  four 
sizes  smaller  than  the  shaft)  will  meet 
the  requirements  of  all  but  exceptional 
cases.  As  manufacturers  of  instru- 
ments do  not  yet  use  a  uniform  scale, 
and  as  most  flexible  instruments  are 
neither  accurately  nor  plainly  marked, 
the  surgeon  should  own  an  accurate 
scale-plate  (Fig.  41),  on  the  two  faces 
of  which  are  marked  French,  English, 
and  American  scales,  as  well  as  inches 
and  millimeters. 

Slwrt  steel  sounds,  made  straight  or 
with  a  very  short  curve  at  the  tip,  are 
convenient  for  use  in  the  anterior  ure- 
thra; they  are,  however,  not  necessary,  since  the  long 
sound  need  be  passed  into  the  urethra  no  further  than 
is  desired. 

The  bulbous  bougie  {bougie  a  boule)  is  the  instrument 
most  used  for  determining  definitely  the  location  and  cali- 
bre of  strictures  (Figs.  42,  43).  The  head  should  be  short, 


Fig.  41  —  Handerson's 
gauge  ^Tiemannj. 


Fig. 


-Bulbous  bougie  (Tiemann) 


and  the  shoulder  should  join  the  much  smaller  shaft  at 
almost  a  right  angle.     These  instruments  made  of  metal 


ORGANIC  STRICTURE    OF  THE    URETHRA. 


535 


are  to  be  preferred  when  large  sizes  are  to  be  used  in 
the  anterior  urethra  only,  but  for  general  use  the  flex- 


Fig.  43.— Elastic  web  bulbous  bougie. 


ible  gum  bougies  a  bottle  are  better.     Otis's  urethrometer 
(Fig.  44)  is  intended  to  serve  the  purpose  of  bulbous 


Open. 
Fig.  44. — Otis's  urethrometer  (Tiemann). 

bougies  of  different  sizes.  After  introduction  into  the 
urethra  the  bulb  may  be  made  larger  or  smaller  as  de- 
sired, and  the  size  is  indicated  on  the  scale  at  the  handle. 
A  soft-rubber  cap  covers  the  bulb,  to  keep  the  wires  from 
tearing  the  mucous  membrane.  This  instrument  is  con- 
venient when  it  works  well  and  is  carefully  manipulated, 
but  it  usually  causes  more  pain  than  do  the  bulbous 
bougies,  and  even  in  careful  hands  the  rubber  cap  is 
liable  to  be  torn  or  to  be  left  in  the  urethra. 

Silver  catheters  should  correspond  in  shape  and  size 
with  the  blunt  steel  sounds.  They  are  of  occasional 
service  in  the  large  sizes,  and  should  be  introduced  in 
the  same  manner  as  the  steel  sound. 

Flexible  bougies  (Fig.  45)  are  necessary  in  the  treat- 
ment of  stricture  of  small  calibre ;  in  the  larger  sizes 
they  are  often  valuable,  especially  for  beginners.  As  a 
rule,  even  the  expert  should  use  flexible  bougies  for  all 
sizes  below  15  or   18,  in  order  to  avoid  the  danger  of 


Fig.  45. — Olivary  gum  bougie  (Tiemann). 

making  a  false  passage.     Of  these  bougies,  the  conical 


536      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

(Fig.  46)  are  the  best  and  most  serviceable,  though  for 
the  larger  sizes  the  olive-tip  bougie,  if  connected  with  the 


Fig.  46. — Conical  bougie. 

shaft  by  a  slender,  perfectly  flexible  neck,  is  preferable. 
They  are  made  in  all  sizes  from  the  filiform  up. 

Flexible  catheters  are  made  of  the  same  size  and  shape 
as  bougies.  Some  of  these  catheters  are  furnished  with 
a  metal  stylet  which  stiffens  them  during  introduction. 
This  stylet  is  of  only  occasional  value.  The  Mercier 
elbowed  (Fig.  47)  and  double  elbowed  catheters  are  ex- 


Fig.  47 — Mercier  elbowed  catheter  (Tiemann). 


cellent  instruments  in  difficult  cases,  and  especially  if  the 
prostate  be  enlarged.  The  tip  should  not  be  too  stiff,  as 
it  often  is  in  those  of  English  manufacture. 


Fig.  48. — Gouley's  whalebone  bougies  (Tiemann). 

Filiform  bougies  (Fig.  48)  are  necessary  in  the  treat- 
ment of  all  strictures  of  very  small  calibre — tight  strictures. 
The  best  filiforms  are  made  of  whalebone  with  fine  bulbous 
tips.  By  placing  them  in  hot  water  for  a  few  minutes 
the  ends  may  be  so  bent  or  twisted  that  the  point  will 
enter  an  eccentric  opening  in  a  stricture  which  a  straight 
instrument  would  be  unable  to  penetrate.  If  the  two 
ends  of  a  filiform  bougie  are  thus  bent  in  the  same  direc- 
tion, when  the  tip  engages  in  the  stricture  the  outer  end 
will  serve  as  an  index  to  the  exact  location  of  the  open- 
ing, which  can  thus  be  found  with  much  less  difficulty  at 
the  next  sitting.  A  filiform  bougie,  when  it  has  been 
passed  through  a  small  and  difficult  opening  in  a  stric- 


ORGANIC  STRICTURE    OF   THE    URETHRA.        537 

ture,  may  be  used  as  a  guide  for  a  larger  instrument. 
For  this  purpose  the  bougie  should  be  at  least  eighteen 
inches  long.  Dr.  E.  A.  Banks  has  devised  a  whalebone 
bougie  which  is  filiform  at  its  tip  and  throughout  its  first 
two  or  three  inches,  and  then  increases  in  size  to  form  a 
larger  shaft  which  can  be  pushed  on  into  the  stricture  to 
dilate  it.  Filiforms  are  also  made  with  caps  on  the  outer 
end  that  can  be  screwed  on  to  larger  instruments  which 
may  thus  be  conducted  through  the  stricture.  These 
bougies  are  dangerous,  as  the  caps  may  become  loose 
and  the  filiform  bougie  may  be  left  in  the  stricture  or  in 
the  bladder ;  besides,  they  offer  no  advantage  over  either 
of  the  two  preceding  methods.  Whalebone  bougies  fre- 
quently become  cracked,  rough,  or  frayed  as  a  result  of 
keeping  and  handling ;  consequently  it  is  necessary  to 
inspect  each  bougie  (as  should  be  done  with  all  soft  in- 
struments) just  before  using,  to  make  sure  that  it  is  sound 
and  smooth. 

Tunnelled  sounds  and  catheters  (Fig.  49)  are  so  made 
that  they  can  be  threaded  over  a  filiform  bougie  and 
thus  be  guided  safely  into  the  bladder.  They  should 
have  a  short  curve,  and  the  short  tunnel  should  be  large 
enough  to  allow  the  guide  to  slip  through  it  easily,  with 
edges  smooth  and  rounded  to  prevent  cutting  the  guide. 
To  use  the  tunnelled  sound  safely  and  to  advantage,  at 
least  five  or  six  inches  of  a  long  filiform  bougie  should 
be   passed  into  the   bladder.     The   tunnelled  sound   is 


Fig.  49. — Gouley's  catheter-staff  (Tiemann). 


then  threaded  over  the  guide  and  slipped  down  to  the 
point  of  the  stricture.     Here  it  is  gently  pressed  forward 


538      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

through  the  stricture  as  the  guide  is  slowly  and  gently 
drawn  out.  If  the  guide  becomes  fast  in  the  larger  in- 
strument, both  guide  and  sound  should  be  withdrawn 
until  the  former  is  again  freely  movable.  Failure  to 
observe  these  precautions  may  result  in  a  false  passage 
or  in  cutting  the  guide  in  two  and  leaving  one  end  of  it 
in  the  stricture. 

Introduction  of  Flexible  Instruments. — In  the  use  of 
soft  and  flexible  instruments  slight  pressure  or  force  is 
allowable,  though  some  of  the  rubber  bougies  are  stiff 
enough  to  do  damage  if  carelessly  used.  The  position 
of  the  penis  during  the  introduction  of  flexible  instru- 
ments is  not  a  matter  of  great  importance  except  for  the 
small-sized  instruments,  for  which  the  penis  should  be 
held  parallel  with  the  thighs  and  should  be  put  lightly  on 
the  stretch,  to  make  the  canal  as  straight  as  possible  and 
to  efface  the  folds  of  mucous  membrane  in  which  the  fine 
points  of  small  instruments  are  frequently  caught. 

For  the  introduction  of  filiform  bougies  the  urethra 
should  first  be  filled  with  warm,  slightly  benzoinated  or 
carbolated  olive  oil.  The  points  of  these  fine  instru- 
ments are  often  caught,  even  in  the  healthy  portion  of 
the  urethra,  by  folds  of  mucous  membrane  or  in  the 
sinuses  of  Morgagni.  When  this  accident  occurs  the 
bougie  is  withdrawn  an  inch  or  more ;  the  tip,  bent  to 
form  an  angle  with  the  shaft,  is  then  rotated  in  another 
direction  and  again  advanced.  These  manoeuvres  are 
repeated  gently,  and,  if  necessary,  many  times,  until 
the  tip  engages  in  the  orifice  of  the  stricture.  To 
determine  whether  a  bougie  has  entered  the  opening 
of  a  stricture  or  a  blind  pocket,  it  should  be  slightly 
withdrawn  and  advanced  :  if  it  be  engaged  in  a  stricture, 
the  grip  of  the  latter  upon  the  instrument  can  be  felt 
plainly  by  the  hand  of  the  operator. 

In  old  and  tortuous  strictures,  with  many  pockets, 
lacunae,  and  partial  false  passages  (Fig.  33)  ready  to 
entangle  the  point  of  a  filiform  bougie,  it  may  be 
impossible    to   find   the   opening  with    a    single    instru- 


ORGANIC  STRICTURE    OF   THE    URETHRA.        539 

ment.  In  such  a  case  a  filiform  bougie  is  passed 
until  it  is  caught,  when  it  is  held  in  place  and 
another  bougie  is  passed  by  its  side.  In  this  way  the 
urethra  may  be  filled  with  a  number  of  these  fine 
instruments,  each  of  which  should  repeatedly  be  with- 
drawn slightly,  partially  rotated,  and  again  advanced, 
until  one  of  them  engages  in  the  orifice  of  the  stricture 
and  passes  into  the  bladder.  The  other  filiforms  should 
then  be  removed.  The  successful  performance  of  the 
procedure  described  above  calls  for  a  steady  hand, 
a  sensitive  and  delicate  touch,  a  large  amount  of  pa- 
tience, and  the  greatest  gentleness  in  every  movement, 
lest  the  mucous  membrane  be  damaged  by  much  manip- 
ulation. The  search  may  sometimes  be  continued  for 
an  hour  or  more,  but  the  production  of  hemorrhage  or 
of  marked  irritation  at  once  renders  further  attempts 
useless  until  the  urethra  has  had  a  rest  of  at  least 
twenty-four  hours.  In  some  instances  the  orifice  of  a 
stricture  may  be  seen  through  an  endoscope,  and  the 
filiform  then  passed  with  ease. 

Relative  Value  of  Steel  and  of  Flexible  Instruments. — 
The  polished  steel  sound,  of  proper  curve,  in  the  hands 
of  an  expert,  can  be  introduced  into  the  urethra  with 
less  discomfort  than  can  any  other  instrument,  but  it 
should  not  be  used  for  sizes  below  15  or  18,  for  fear  of 
making  a  false  passage.  For  the  smaller  sizes  the  flexi- 
ble instruments  are  safer  and  better.  They  may  often 
be  used  in  the  larger  sizes  to  advantage.  The  chief 
objections  to  them  are  that  they  produce  more  irritation 
in  the  urethra,  and  therefore  more  frequently  provoke 
urethral  spasm,  and  that  they  are  less  rapidly  effective 
in  dilating  stricture  than  the  steel  sound  when  the  latter 
is  used  with  sufficient  skill  and  care.  They  are,  more- 
over, more  difficult  to  clean  and  less  durable.  On  the 
other  hand,  they  are  not  capable  of  doing  so  much 
damage  when  used  by  one  not  specially  trained  in  the 
proper  introduction  of  the  steel  sound.  The  best 
flexible    instruments    have   a  foundation  of  woven   silk, 


540      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

covered  with  a  smooth  elastic  composition.  These  are 
higher  priced  than  the  inferior  grades,  but  their  dura- 
bility makes  them  more  economical  in  the  end.  They 
are  also  smoother,  stronger,  and  more  supple.  Many 
good  woven  web  instruments  are  made  of  linen.  The 
cheaper  grades  with  which  the  market  is  flooded 
are  not  to  be  relied  upon.  When  new  and  in  cool 
weather,  the  black  French  instruments  are  softer  and 
better  than  the  English,  but  they  do  not  last  so  long ; 
in  hot  weather  they  often  become  too  limp  to  be  of 
use  and  are  easily  spoiled,  as  softening  of  their  outer 
coating  allows  them  to  stick  together  and  become 
rough.  The  English  (yellow)  bougies  are  firmer  and 
more  durable,  and,  if  the  softer  ones  be  selected,  are  the 
best.  If  too  stiff,  they  can  be  made  more  flexible  by 
placing  them  in  hot  water  for  a  few  minutes  just  before 
using.  American  manufacturers  are  now  making  silk 
and  linen  web  catheters  and  bougies  of  as  good  quality 
as  can  be  found  anywhere. 

In  selecting  woven  bougies  and  catheters,  those  should 
be  chosen  which  are  supple  and  flexible,  especially  for 
two  or  three  inches  back  of  the  point,  and  which  are 
well  coated  with  a  smooth  and  unbroken  varnish.  It  is 
important  that  catheters  are  as  well  coated  inside  as  they 
are  outside,  so  that  they  may  be  properly  cleaned. 
Further,  the  tip  in  front  of  the  eye  should  be  solid,  in- 
stead of  having  a  pocket  in  which  to  retain  dirt  and 
septic  matter.  The  well-made  pure-gum  catheters  are 
the  best  for  general  use,  as  they  are  easily  cleaned  and 
sterilized  by  boiling,  but  for  some  purposes  they  are  not 
stiff  enough. 

All  flexible  instruments  sooner  or  later  wear  out  or 
become  hard  and  brittle ;  consequently  they  should 
always  be  examined  just  before  using,  to  make  sure  that 
they  are  sound  and  smooth,  and  their  tensile  strength 
tested  by  pulling  on  the  tip.  This  remark  is  especially 
true  of  the  soft  catheters,  made  without  the  woven 
foundation,  which  every  general  practitioner  is  supposed 


ORGANIC  STRICTURE    OF  THE    URETHRA.        541 

to  carry  in  his  case.  It  happens  occasionally  that  the 
tip  of  one  of  these  old  instruments  breaks  off  and  is 
left  in  the  urethra.  Fortunately,  in  the  majority  of 
cases,  if  left  alone,  the  constriction  about  the  piece 
relaxes  after  a  few  hours,  and  the  fragment  is  washed 
out  during  the  next  urination. 

Care  of  Instruments. — The  principles  of  antiseptic 
surgery  should  be  followed  strictly  in  the  care  and  use 
of  all  urethral  instruments.  Failure  to  observe  these 
principles  too  often  results  in  urethral  fever,  urethritis, 
cystitis,  epididymitis,  prostatitis,  abscess,  and  other  dis- 
agreeable and  dangerous  complications.  All  instruments, 
immediately  after  use,  should  be  washed  thoroughly 
with  soap  and  warm  water.  Catheters  should  have 
soapy  water  forced  through  them.  Antiseptic  solutions 
have  little  effect  upon  an  instrument  covered  with  oil  or 
vaseline  and  smeared  with  pus,  blood,  or  other  matter. 
Moreover,  if  rubber  instruments  are  allowed  to  remain 
covered  with  oil,  vaseline,  or  fat,  they  soon  become 
rough  and  useless.  Steel  instruments  are  best  sterilized 
by  boiling  or  by  placing  them  for  twenty  minutes  or 
half  an  hour  in  a  steam-sterilizer.  Before  use  they  may 
be  placed  for  a  few  minutes  in  a  5  per  cent,  carbolic-acid 
solution ;  or  they  may  be  passed  through  the  flame  of 
an  alcohol  lamp  or  Bunsen  burner.  Pure-gum  catheters 
may  be  sterilized  by  boiling.  Varnished  and  whalebone 
instruments  may  be  placed,  before  use,  in  a  solution  of 
bichloride  of  mercury,  1  :  1000.  The  most  satisfactory 
disinfection  of  flexible  instruments  is  by  means  of  for- 
maldehyde vapor.  Several  excellent  and  convenient 
devices  for  this  purpose  are  now  for  sale  by  the  instru- 
ment-makers. As  instruments  so  treated  are  some- 
times irritating  to  the  urethra,  it  is  well  to  place  them 
for  a  few  minutes  before  use  in  sterile  water,  or  to  wipe 
them  with  sterile  gauze. 

Steel  instruments  should  be  kept  in  cases  made  to  fit 
them,  as  they  are  otherwise  easily  nicked  or  scratched. 
The  slightest  defect,  such  as  a  scratch  or  a  rust-spot,  in 


542      SYPHILIS  AND    THE  VENEREAL    DISEASES. 

the  surface  of  an  instrument  may  cause  urethral  irrita- 
tion, and  may,  moreover,  serve  as  the  lodging-point  of 
infectious  matter.  Such  an  instrument  should  always 
be  laid  aside  until  properly  repaired.  Flexible  instru- 
ments should  be  kept  between  layers  of  cotton  or 
gauze,  or  in  narrow  pasteboard  trays  lined  with  paper 
that  is  thrown  away  when  soiled.  They  should  be  laid 
straight  and  not  bent  or  coiled.  In  hot  weather  they 
should  be  dusted  with  finely  powdered  talc  or  otherwise 
separated,  to  keep  them  from  adhering — an  accident  that 
almost  invariably  roughens  and  ruins  the  instrument. 

Cutting  instruments  and  the  methods  of  their  use  are 
described  in  connection  with  the  operations  for  which 
they  are  intended.  For  the  benefit  of  the  beginner, 
a  summary  of  all  other  instruments  necessary  in  the 
diagnosis  and  treatment  of  stricture  is  here  given. 
The  French  scale  is  used,  and  in  forming  sets  of  in- 
struments every  other  (odd  or  even)  number  may  be 
omitted. 

Ten  conical  steel  sounds,  Nos.  15  to  35  ;  a  corre- 
sponding set  of  short  steel  sounds,  for  use  in  the  anterior 
urethra  (convenient,  but  not  necessary) ;  two  or  three 
silver  catheters,  Nos.  18.  to  24;  a  set  of  bulbous  bougies, 
Nos.  7  to  35  (the  larger  sizes  may  be  metallic  if  pre- 
ferred) ;  a  set  of  French  or  English  conical,  flexible 
bougies,  Nos.  5  to  20,  or  to  33  if  desired;  half  a  dozen 
soft  catheters,  Nos.  6  to  20 ;  as  many  Mercier  catheters, 
and  one  or  two  of  larger  size ;  half  a  dozen  short  and 
three  or  four  long  whalebone  filiform  bougies ;  a  set  of 
tunnelled  conical  steel  sounds  with  short  curve,  Nos. 
6  to  18;  two  or  three  tunnelled  (not  conical)  catheters, 
Nos.  6  to  10;  a  Banks  whalebone  bougie;  and  an  accu- 
rate gauge.  If  the  surgeon  is  within  easy  reach  of  sur- 
gical supplies  the  number  of  soft  catheters  should  be 
reduced,  as  these  instruments  often  deteriorate  and 
become  useless  after  a  few  months. 

Diagnosis. — The  instruments  of  precision  furnished 
the  surgeon  render  the  diagnosis  of  stricture  compara- 


ORGANIC  STRICTURE    OF   THE    URETHRA.        543 

tively  easy.  The  chief  difficulty  at  present  lies  in  distin- 
guishing between  beginning  strictures  of  large  calibre 
and  normal  points  of  narrowing  in  the  urethral  wall. 

The  indications  for  exploring  the  urethra  are  found  in 
the  presence  of  one  or  more  of  the  symptoms  of  stricture, 
already  described,  appearing  a  number  of  months  or 
years  after  urethritis  (usually  prolonged  gonorrhoea)  or 
urethral  injury.  Needless  instrumentation  of  the  urethra 
should  always  be  avoided.  Though  the  proper  explora- 
tion of  the  urethra  is  usually  attended  by  no  worse  re- 
sults than  some  discomfort  or  pain  to  the  patient  and 
some  smarting  or  burning  in  the  urethra  at  the  next 
micturition,  it  happens  occasionally  that  the  apparently 
careful  and  skilful  passage  of  a  steel  sound  through  a 
normal  urethra  is  followed  by  syncope,  shock,  urethral 
fever,  epididymitis,  prostatitis,  etc.  If  the  urethra  be 
diseased,  if  force  be  used,  if  the  operator  be  careless  or 
unskilled,  or  if  his  instruments  be  rough  or  soiled,  these 
and  other  yet  more  unfortunate  results  of  urethral  instru- 
mentation occur  not  infrequently.  Instruments  should 
not  be  used  in  the  urethra  if  there  be  a  decided  discharge 
from  the  meatus,  or  other  evidences  of  urethral  inflam- 
mation or  irritation. 

Exploration  of  the  urethra  for  the  first  time  should  be 
begun  by  the  introduction  of  a  blunt  steel  sound  of  the 
largest  size  that  will  pass  the  meatus  without  stretching 
the  latter  sufficiently  to  cause  pain  or  to  produce  the 
characteristic  evidence  of  an  over-stretched  meatus — 
namely,  a  narrow  white  (anaemic)  line  at  the  edge  of  the 
orifice  and  in  contact  with  the  instrument.  As  a  mile, 
if  such  an  instrument  pass  easily  into  the  bladder,  stric- 
ture is  absent.  The  exceptions  to  this  rule  are  consid- 
ered later.  If  the  instrument  meets  with  obstruction  in 
the  urethra  and  fails  to  pass,  a  series  of  blunt  sounds 
gradually  decreasing  in  size  should  be  used  until  one 
is  passed.  Below  size  15,  soft  instruments  should  be 
used.  When  an  instrument  has  been  passed,  it  should 
be  left  in  position  (unless  it  is  producing  pain  or  irrita- 


544      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

tion)  long  enough  for  the  fingers  to  explore  the  pendu- 
lous urethra  for  external  evidences  of  stricture,  which 
may  be  found  in  the  form  of  circular  or  irregular  bands 
of  thickening  and  induration.  In  this  way  valuable  in- 
formation may  be  gained,  and  further  instrumentation 
for  purposes  of  diagnosis  is  often  rendered  unnecessary. 

In  many  cases,  however,  accurate  location  and  meas- 
urement of  stricture  is  best  accomplished  by  the  use  of 
bulbous  bougies.  An  instrument  with  a  bulb  corre- 
sponding in  size  to  the  sound  that  has  passed  the  stric- 
ture is  properly  prepared  and  gently  inserted  down  to 
the  anterior  face  of  the  stricture,  where  it  is  arrested. 
\{  the  bulb  does  not  pass  the  stricture,  a  smaller  instru- 
ment is  selected  and  passed  into  the  bladder.  As  it  is 
withdrawn  it  is  again  arrested  as  its  shoulder  reaches 
the  posterior  surface  of  the  stricture.  If  the  distance  of 
the  meatus  from  the  end  of  the  handle  be  measured  and 
noted  when  the  bulb  is  arrested,  both  in  entering  and  in 
withdrawing,  not  only  the  location  and  calibre  but  also 
the  approximate  thickness  of  the  stricture  may  be  de- 
termined. In  those  unusual  cases  in  which  stricture  is 
multiple  there  is  no  difficulty  in  locating  and  measuring 
each,  if  the  anterior  stricture  is  of  larger  calibre  than  the 
deeper  one.  If  the  reverse  is  true  the  Otis  urethrometer 
may  be  used,  though  the  diagnosis  of  the  deeper  stricture 
is  of  less  practical  value,  since  it  does  not  call  for  treat- 
ment until  the  stricture  in  front  of  it  has  been  dilated. 

Several  sources  of  error  should  always  be  considered 
in  the  use  of  bulbous  instruments.  They  produce  more 
irritation,  and  therefore  more  frequently  provoke  urethral 
spasm,  than  do  blunt  or  conical  sounds,  and,  moreover, 
they  are  less  effective  than  the  latter  in  overcoming 
spasm  or  in  detecting  the  characteristics  which  distin- 
guish it  from  organic  stricture.  In  withdrawing  the 
instrument  the  shoulder  of  the  bulb,  in  passing  from  the 
prostatic  to  the  membranous  urethra,  frequently  catches 
on  the  posterior  layer  of  the  triangular  ligament  and 


ORGANIC  STRICTURE    OF   THE    URETHRA.        545 

produces  a  sensation  closely  resembling  that  produced 
by  stricture.  In  the  pendulous  urethra  the  shoulder  of 
the  bulb  may  be  arrested  at  one  or  more  points  of  nor- 
mal narrowing  frequently  found  in  the  first  three  inches 
from  the  meatus.  The  danger  of  error  in  diagnosis  is 
lessened  if  the  bulbs  be  used  in  connection  with  the  steel 
sound  as  above  described. 

The  reasons  for  beginning  with  a  full-sized  steel  sound 
are  several  :  it  produces  less  irritation  than  any  other 
instrument ;  often,  it  will  easily  enter  the  bladder  when 
bulbous  sounds  or  smaller  instruments  fail  to  pass  be- 
cause of  the  spasm  excited  or  because  of  the  finer  points 
being  caught  in  some  of  the  folds  or  sinuses  of  the 
urethra;  its  ready  passage  may  save  much  unnecessary 
instrumentation  and  irritation  of  the  urethra;  the  intro- 
duction of  one  or  more  steel  sounds  in  a  urethra  lessens 
for  a  time  the  sensitiveness  of  the  mucous  membrane,  so 
that  other  instruments  which  follow  produce  less  irrita- 
tion and  spasm  than  if  used  first. 

As  a  rule,  the  first  sitting  should  be  made  as  short  as 
possible,  since  strictures — and  individuals  also — vary 
greatly  in  the  amount  of  instrumentation  they  will 
endure  without  unfavorable  results.  If  the  introduction 
of  the  first  sound  proves  very  irritating,  as  may  happen 
in  nervous  men,  it  is  often  wise  to  postpone  further  at- 
tempts for  a  day  or  two,  even  though  the  bladder  has 
not  been  entered.  After  locating  and  measuring  the 
stricture,  unless  there  be  urgent  symptoms  demanding 
immediate  attention,  no  attempt  at  dilatation  should  be 
made  for  two  or  three  days,  until  the  irritation  which 
will  probably  result  from  the  examination  has  subsided, 
and  the  surgeon  is  given  a  chance  to  gain  some  idea  of 
how  sensitive  the  patient  and  his  stricture  are  to  instru- 
mentation. The  patient  should  be  warned  that  the  next 
urination  will  probably  be  attended  by  some  discomfort, 
and  that  he  may  notice  a  slight  discharge  from  the 
meatus,  or  an  aggravation  of  an  existing  one,  for  a  few 
days.     If  indicated,  an  alkali  or  one  of  the  balsams  may 

35 


546      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

be  ordered,  while  small  doses  of  quinine  may  be  given 
to  lessen  the  danger  of  urethral  fever. 

The  general  health  and  habits  of  the  patient  should 
be  investigated  fully,  and  necessary  corrections  should 
be  made.  Of  particular  importance  is  a  careful  exami- 
nation of  the  urine.  If  the  latter  contains  pus,  and  espe- 
cially if  it  is  decomposed  and  indicates  the  presence  of 
cystitis,  the  patient  should  at  once  be  put  upon  urotropin 
in  5-  to  8-grain  doses,  or  boric  acid  or  salol  in  10-grain 
doses  four  times  a  day,  to  lessen  the  danger  of  urethral 
fever  and  other  complications.  The  amount  of  residual 
urine  in  the  bladder  should  be  ascertained  by  passing  a 
catheter  immediately  after  the  patient  has  urinated. 

The  accurate  diagnosis  of  strictures  of  large  calibre 
may  require  cutting  of  the  meatus  before  instruments 
of  sufficient  size  can  be  introduced  into  the  urethra. 
Until  recently  many  surgeons,  acting  under  the  impres- 
sion that  the  operation  was  simple  and  harmless,  have 
cut  the  meatus  frequently  and  freely,  simply  as  a  matter 
of  convenience  in  searching  for  possible  stricture  of 
large  calibre.  There  is  no  doubt  that  the  operation  is 
often  followed  by  harmful  results.  The  gaping  lips  of 
a  freely  cut  meatus  are  frequently  the  seat  of  a  persistent 
gleety  discharge,  while  the  operation  may  greatly  lessen 
the  power  of  the  individual  to  eject  urine  and  semen 
from  his  urethra,  so  that  dribbling  of  urine  after  mic- 
turition is  not  uncommon  in  these  cases.  If  the  meatus 
is  abnormally  small,  and  especially  if  it  is  rendered  so 
by  a  thin  band  of  tissue  at  the  lower  commissure, 
meatotomy  should  be  performed  to  allow  the  entrance 
of  a  full-sized  sound.  The  free  division  of  the  meatus, 
however,  to  allow  the  introduction  of  very  large  instru- 
ments is  not  warranted  unless  there  be  other  and 
more  urgent  symptoms  of  stricture  than  a  gleety  dis- 
charge, or  unless  the  latter  has  persisted  for  a  year  or 
more  notwithstanding  skilful  and  faithful  treatment,  in- 
cluding the  best  general  and  hygienic  management.     In 


ORGANIC  STRICTURE    OF  THE    URETHRA.        547 

such  a  case  it  is  possible  that  a  forming  stricture,  of  a 
calibre  as  yet  too  large  to  interfere  with  the  passage  of 
an  instrument  of  ordinary  size,  is  responsible  for  the 
discharge,  and,  after  other  means  of  treatment  have  been 
tried,  exploration  of  the  urethra  with  instruments  larger 
than  will  pass  the  normal  meatus  is  proper. 

In  such  an  examination  the  question  at  once  arises, 
What  constitutes  the  normal  calibre  of  the  urethra,  and 
what  size  of  instrument  should  pass  unobstructed  into 
the  bladder?  On  this  point  authorities  differ,  and  it  is 
evident  that  an  exact  answer  to  this  question  cannot  be 
given,  since  the  urethra  is  not  a  tube  of  uniform  diame- 
ter, but  is  a  closed  canal  or  valve  having  normal  points 
of  narrowing.  Dr.  Otis  maintains  that  the  calibre  of 
the  urethra  bears  a  constant  relation  to  the  circumfer- 
ence of  the  flaccid  penis.  But  that  such  a  relation  is 
only  approximate  is  evident  when  one  considers  the 
great  variations  in  the  size  of  the  organ  under  the  in- 
fluence of  heat,  cold,  mental  state,  etc.  Dr.  Otis's  scale, 
which  is  much  too  large,  is  as  follows  :  When  the  cir- 
cumference of  the  flaccid  penis  is  3  inches,  the  urethra 
should  receive  an  instrument  of  the  size  30 ;  3^  inches, 
size  32  ;  3 J  inches,  size  34;  3I  inches,  size  36;  4  inches, 
size  38;  a,\  to  4!  inches,  size  40.  These  sizes  do  not 
indicate  the  normal  calibre  of  the  urethra,  but  the  limit 
to  which,  according  to  Dr.  Otis,  the  urethra  can  safely  be 
distended.  For  purposes  of  diagnosis  and  treatment 
the  majority  of  modern  surgeons  adopt  a  scale  from  four 
to  eight  sizes  smaller  than  those  named  above ;  they  also 
recognize  normal  variations  in  the  pendulous  urethra. 

Many  surgeons  who  adopt  the  larger  scale  find  and 
treat  a  great  many  so-called  "  strictures  of  large  calibre  " 
that  are  really  nothing  more  than  simple,  normal  con- 
tractions of  the  urethra.  This  unnecessary  stretching 
and  cutting  of  the  urethra  not  infrequently  results  in 
permanent  and  even  distressing  deformity. 

The  diagnosis  of  stricture  should,  then,  be  reserved 
for  a  distinct  contraction  of  the  urethra,  accompanied  by 


54§      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

a  gleety  discharge,  frequent  micturition,  dribbling  of  urine 
after  urination,  or  other  symptoms  of  stricture. 

Prostatic  hypertrophy  may  lead  to  a  careless  diagnosis 
of  stricture  of  the  deep  urethra,  but  in  the  former  dis- 
order the  obstruction  to  the  sound  is  situated  more  than 
six  and  a  half  inches  from  the  meatus ;  the  handle  of 
the  sound  must  be  depressed  considerably  more  than 
usual  before  the  tip  enters  the  bladder ;  a  rectal  exam- 
ination reveals  the  enlarged  prostate ;  the  patient  usually 
is  over  fifty  years  of  age ;  and  there  is  a  history  of  grad- 
ually increasing  frequency  of  micturition,  most  marked 
at  night. 

Treatment. — The  directions  already  given  for  instru- 
mentation of  the  urethra  are  not  repeated  here,  although 
their  observance  forms  a  necessary  and  most  important 
part  of  the  treatment  of  stricture.  It  should  never  be 
forgotten  by  the  operator  that  the  exercise  of  gentleness, 
caution,  and  patience  is  not  only  less  dangerous  but  far 
more  effective  in  the  treatment  of  stricture  than  is  the 
employment  of  force. 

Dilation. — In  the  large  majority  of  strictures,  either 
of  the  deep  or  of  the  pendulous  urethra,  that  are  not 
complicated  by  retention  or  by  other  urgent  symptoms, 
gradual  dilation  is  the  most  efficient  and  safest  method 
of  treatment.  By  this  method  the  stricture  is  dilated 
during  successive  sittings  by  a  series  of  sounds  gradually 
increasing  in  size.  The  principles  given  for  the  intro- 
duction of  the  steel  sound  should  be  carefully  studied 
and  applied.  Each  sound  or  bougie  should  be  cleaned, 
sterilized,  warmed,  and  lubricated  before  it  is  used  in  the 
urethra.  To  further  lessen  the  danger  of  urethral  fever 
during  treatment,  the  patient  should  take  10  or  15  grains 
of  boric  acid  or  of  salol  four  times  a  day  for  thirty-six 
or  forty-eight  hours  before  and  for  an  equal  time  after 
each  sitting.  The  general  health  of  the  patient  should 
be  maintained,  and  he  should  fully  understand  that  the 
success  of  the  treatment,  as  well  as  freedom  from  dis- 
tressing complications  which  delay  progress,  will  depend 


ORGANIC  STRICTURE    OF   THE    URETHRA.        549 

largely  upon  his  living  simply  and  hygienically.  To- 
bacco, alcohol,  and  other  stimulants,  sexual  indulgence, 
and  severe  exercise  are  especially  harmful.  Frequent 
examinations  of  the  urine,  and  especially  of  the  residual 
urine,  are  necessary  to  keep  the  surgeon  informed  regard- 
ing the  condition  of  the  bladder  and  of  the  kidneys. 

In  strictures  of  large  calibre  the  dilation  is  best  ac- 
complished by  means  of  conical  steel  sounds.  There 
is  selected  a  sound  of  the  same  size  as  the  exploring 
instrument  that  entered  the  stricture  during  the  ex- 
amination of  two  or  three  days  previous ;  this  sound 
is  gently  passed  through  the  stricture.  If  it  occasions 
no  distress,  it  should  be  allowed  to  remain  in  situ 
for  five  or  ten  minutes ;  it  is  then  withdrawn  gently 
and  the  next  larger  size  is  used  in  the  same  manner. 
For  dilating  strictures  of  the  deep  urethra  the  Beneque 
sound  (Fig.  50)  is  often    convenient,  since   the    handle 


Fig.  50. — Beneque  sound. 

may  be  brought  to  the  horizontal  and  full  stretching  of 
the  stricture  accomplished  without  interfering  markedly 
with  the  normal  curve  of  the  urethra.  If  the  stricture 
is  in  the  pendulous  urethra,  a  short  sound  should  be 
used,  or  the  long  sound  should  be  arrested  before  enter- 
ing the  bladder,  to  avoid  unnecessary  irritation.  Usually 
the  stricture  may  thus  be  dilated  two  or  three  numbers 
(French  scale)  at  each  sitting;  but  occasionally  the 
same  sound  must  be  passed  at  several  successive  sit- 
tings before  a  larger  one  can  be  employed.  This  is  a 
matter  that  must  be  decided  in  each  case  by  the  surgeon 
in  attendance,  after  watching  the  effect  of  instrumenta- 
tion upon  the  stricture  and  upon  the  individual.  Dila- 
tion  should  be  stopped   for    that   day  whenever  it  has 


550      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

been  carried  far  enough  to  produce  a  drop  or  two  of 
blood  or  to  cause  decided  pain  or  irritation.  It  is  better  to 
stop  a  little  short  of  producing  these  symptoms.  When 
attempts  at  dilation  are  followed  by  marked  urethral 
irritation,  with  possibly  slight  pain  in  the  testicles,  and 
especially  if  a  suggestion  of  chill  or  fever  has  resulted, 
the  surgeon  will  content  himself  with  slower  progress. 
There  is  nearly  always  a  temptation  to  use  a  little  force 
and  haste,  but  such  attempts  are  usually  followed  by 
urethritis,  epididymitis,  or  urethral  fever,  necessitating 
the  suspension  of  further  dilation  until  the  new  com- 
plication is  removed.  The  conical  steel  sound  is  not 
only  a  powerful  lever  of  the  first  class,  but  it  is  also  a 
wedge,  and  few  surgeons  realize,  until  they  have  pro- 
duced a  false  passage  or  met  with  other  misfortune,  how 
much  force  very  slight  pressure  upon  the  handle  may 
cause  the  point  of  such  a  sound  to  exert  in  the  (usually 
damaged)  urethra.  Slight  force  may  occasionally  be 
necessary  in  the  use  of  blunt  instruments,  but  if  a  con- 
ical steel  sound,  properly  held  against  a  stricture  for  a 
few  seconds,  refuses  to  pass  by  its  own  weight,  it  should 
be  withdrawn  and  a  smaller  size  be  substituted. 

At  each  sitting  the  dilation  should  be  begun  by  the 
introduction  of  a  sound  one  or  two  sizes  smaller  than 
the  largest  sound  used  at  the  previous  visit.  It  is 
always  best  to  have  the  patient  urinate  in  the  surgeon's 
presence  before  passing  the  sounds,  that  the  urethra 
may  be  cleansed  by  the  urine,  that  the  size  of  the 
stream  and  the  condition  of  the  urine  may  be  tested, 
and  that  the  first  urination  after  the  operation  may  be 
postponed  for  a  few  hours. 

Valuable  information  bearing  on  the  treatment  of 
stricture  may  be  obtained  by  watching  the  phenomena 
following  the  introduction  of  a  sound  into  a  stricture 
which  is  thus  stretched  slightly.  When  the  instrument 
first  enters,  it  is  more  or  less  tightly  grasped,  so  that 
some  force  may  be  necessary  to  remove  it,  but  if  allowed 
to  remain  in  situ  a  few  seconds  or  minutes,  the  stricture 


ORGANIC  STRICTURE    OF   THE    URETHRA.        55 1 

relaxes  and  the  sound  moves  through  it  easily ;  the 
spasmodic  element  has  been  overcome  and  the  stricture 
has  been  stretched  mechanically.  As  a  rule,  the  stream 
of  urine  is  increased  in  size  for  a  short  time — possibly 
twenty-four  hours — before  congestion,  or  even  inflamma- 
tion, in  and  about  the  stricture-growth  follows ;  the 
resulting  swelling  narrows  the  calibre  of  the  urethra 
and  therefore  the  size  of  the  stream.  At  this  time  there 
is  usually  an  increase  in  the  discharge  from  the  meatus, 
with  other  symptoms  indicating  irritation  or  inflamma- 
tion of  the  urethra.  At  the  end  of  three  or  four  days 
absorption  begins  ;  the  calibre  of  the  stricture,  and  hence 
the  size  of  the  stream,  enlarges  ;  the  urethral  discharge 
and  other  symptoms  improve.  This  improvement  con- 
tinues from  a  day  or  two  to  a  week  before  contraction 
again  begins. 

It  is  evident  to  one  who  stops  to  consider  the  signif- 
icance of  the  above-described  phenomena  that  after 
stretching  a  stricture  the  next  attempt  at  dilation  should 
be  postponed  at  least  beyond  the  stage  of  contraction 
and  irritation ;  indeed,  the  best  results  are  obtained 
when  such  instrumentation  is  delayed  until  just  before 
the  stricture  again  begins  to  contract.  When  the  same 
instrument  that  was  used  a  day  or  two  before  to  dilate  a 
stricture  is  reintroduced  during  the  resulting  stage  of 
congestion,  it  passes  with  more  difficulty  and  produces 
much  more  pain  and  irritation  than  when  passed  the  first 
time.  Unless  the  operator  appreciates  the  situation,  he 
will  probably  conclude  that  he  has  an  irritable  stricture 
to  deal  with.  A  great  many  irritable  strictures  are  un- 
doubtedly produced  in  just  this  way,  as  the  result  of  too 
frequent  and  injudicious  instrumentation.  The  com- 
monest mistakes  in  the  treatment  of  stricture  are  of  this 
charater,  and  beginners  especially  are  inclined  to  make 
the  intervals  between  visits  for  dilation  altogether  too 
short.  The  results  of  such  over-treatment  are  slow 
progress  or  none  at  all,  an  irritable  stricture,  a  con- 
stantly   congested    and    inflamed    urethra,    and    not    in- 


552      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

frequently  more  serious  complications.  In  different 
cases  the  proper  interval  may  vary  from  three  to  ten 
days,  depending  upon  the  character  of  the  stricture,  the 
amount  of  dilation  accomplished  each  time,  the  amount 
and  nature  of  the  reaction,  and  the  general  health  and 
habits  of  the  individual.  The  decision  must  be  based 
on  a  careful  study  of  each  case,  and  especially  of  the 
phenomena  described  above.  In  the  majority  of  cases 
in  which  steel  sounds  are  used,  the  most  rapid  progress 
and  the  best  results  in  dilation  of  stricture  are  obtained  by 
sittings  with  intervals  averaging  from  five  to  seven  days. 
The  treatment  should  be  continued  steadily  through 
several  weeks  until  the  stricture  has  been  dilated  to  the 
normal  calibre  of  the  urethra.1  By  this  time  the  symp- 
toms will  usually  have  disappeared,  with  the  exception 
of  traces  of  the  gleety  discharge,  which  will  probably 
disappear  as  instrumentation  is  suspended. 

The  treatment  must  not  end  here,  however,  if  it  is  to 
result  in  any  permanent  benefit,  for  if  left  alone  the  great 
majority  of  strictures  will  at  once  begin  to  re-contract. 
The  patient  should  clearly  understand  that  unless  the 
calibre  of  the  urethra  be  maintained  by  the  occasional 
use  of  a  sound,  contraction  of  the  stricture  will  follow, 
and  his  treatment  will  prove  of  no  permanent  value. 

To  prevent  re-contraction  a  full-sized  sound  should  be 
passed  with  sufficient  frequency.  At  first  this  procedure 
should  be  done  once  in  a  week  or  ten  days,  then  once 
in  two  weeks,  the  intervals  thus  being  lengthened  grad- 
ually until  the  sound  is  no  longer  needed  or  until  it  is 
discovered  how  long  the  interval  may  be  made  before 
the  stricture  begins  to  contract.  A  few  months  of  such 
treatment  will  render  further  instrumentation  unneces- 
sary in  some  cases,  but  usually  the  introduction  of  the 
sound  must  be  repeated,  at  intervals  varying  from  a 
week  to  three  months,  for  several  years,  or  even  in- 
definitely. 

1  The  question  of  what  constitutes  the  normal  calibre  of  the  urethra  is 
considered  in  connection  with  diagnosis. 


ORGANIC  STRICTURE    OF  THE    URETHRA.        553 

With  a  little  instruction  the  patient  should,  as  a  rule, 
learn  to  pass  the  full-sized  sound  upon  himself,  thus  ob- 
viating the  necessity  of  occasional  visits  to  the  surgeon 
during  long  periods  of  time,  and  also  lessening  the  prob- 
ability of  neglect.  The  patient  should  be  impressed 
especially  with  the  necessity  of  keeping  his  sound  clean 
and  aseptic.  If  such  a  course  of  dilation  be  faithfully 
carried  out,  many  strictures  disappear  entirely,  while 
others,  with  a  little  care  on  the  part  of  the  patient,  are 
kept  under  control  and  rendered  harmless. 

That  absorption  of  the  stricture-growth  during  a 
course  of  gradual  dilation  actually  occurs  can  often 
be  demonstrated  by  watching  the  progress  of  a  case  in 
which  the  growth  can  be  felt  by  the  fingers  on  the  out- 
side and  its  gradual  disappearance  be  noted. 

In  strictures  of  small  calibre  uncomplicated  by  re- 
tention or  other  urgent  symptoms,  gradual  dilation  is 
carried  on  as  above  described,  except  that  flexible  in- 
struments should  be  used  until  the  stricture  is  dilated 
sufficiently  to  receive  a  No.  15  or  18  sound.  The  great 
danger  of  making  a  false  passage  in  using  a  conical 
steel  sound  smaller  than  No.  1 5  cannot  be  too  strongly 
impressed  upon  those  who  have  never  had  an  oppor- 
tunity to  observe  how  easily  this  unfortunate  accident 
can  occur.  Though  with  steel  sounds  progress  is  more 
rapid  and  discomfort  to  the  patient  is  less,  yet  for  all 
sizes  below  No.  15  or  18  soft  instruments  should  be 
used. 

Since  less  dilation  is  usually  accomplished  at  each 
sitting  with  the  flexible  bougies  than  with  sounds,  the 
resulting  congestion  and  irritation  are  less  and  subside 
more  rapidly,  so  that  the  intervals  between  sittings 
should  be  shorter.  The  proper  interval  varies  from  two 
to  five  days,  and  should  be  determined  in  each  case  in 
the  same  manner  as  when  sounds  are  used. 

In  some  cases  of  old  stricture,  though  the  patient  be 
able  to  pass  a  small  stream  of  urine,  great  difficulty  is 
experienced   in   introducing   even  the  finest  instrument. 


554      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

The  opening  is  usually  eccentric  and  may  possibly  be 
covered  with  a  flap  of  mucous  membrane ;  or  the  canal 
through  the  stricture  is  tortuous  and  presents  many 
small  pockets,  open  follicles,  or  false  passages  (Fig.  33). 
Such  strictures  are  often  termed  "  impassable,"  but  so 
long  as  a  stricture  has  a  calibre  sufficient  to  allow  the 
escape  of  urine,  it  is  possible  to  enter  it  with  filiform 
bougies  if  these  be  used  with  the  proper  skill,  patience, 
and  perseverance.  The  methods  of  using  filiform  bou- 
gies have  already  been  described  in  detail. 

It  sometimes  happens  that  a  number  of  prolonged 
sittings  at  intervals  of  a  day  or  two  are  necessary  before 
an  instrument  can  be  made  to  enter  the  stricture ;  but 
these  attempts  should  not  be  given  up  unless  there  be 
retention  or  other  urgent  symptoms  demanding  imme- 
diate relief,  or  unless  the  use  of  instruments  is  followed 
by  urethral  fever  or  by  other  unfavorable  result.  Some- 
times the  end  of  the  bougie  enters  the  stricture  far 
enough  to  be  grasped,  but  will  pass  no  further.  In 
such  a  case  the  bougie  should  be  left  in  this  position  for 
ten  or  fifteen  minutes,  when  it  probably  can  be  intro- 
duced still  further.  If  it  refuses  to  pass  further  at  the 
end  of  half  an  hour,  it  may  be  tied  in  place  and  left  for 
twenty-four  hours,  at  the  end  of  which  time,  if  it  will 
not  enter  the  bladder,  it  will  at  least  have  dilated  the 
anterior  portion  of  the  stricture,  which  will  consequently 
be  more  readily  entered  by  other  instruments,  some  of 
which  will  eventually  pass  to  the  bladder. 

When  a  filiform  bougie  has  passed  a  stricture  the 
next  step  in  treatment  depends  on  a  number  of  con- 
ditions. The  choice  of  operation  lies  between  (1)  con- 
tinuous dilation  (2)  immediate  passage  of  a  tunnelled 
catheter  over  the  filiform  to  the  bladder,  and  (3)  ure- 
throtomy. If  the  previous  manipulations  have  caused 
little  urethral  irritation,  if  there  are  no  symptoms  de- 
manding immediate  interference,  and  especially  if  the 
operator  has  located  the  opening  of  the  stricture,  so 
that  he  can  find  it  readily  at  the  next  visit,  the  bougie 


ORGANIC  STRICTURE    OF   THE    URETHRA.        555 

should  be  left  in  place  for  from  fifteen  minutes  to  an 
hour  and  then  be  removed.  Retention  due  to  swelling 
of  the  mucous  membrane  may  follow,  but  it  rarely  lasts 
for  more  than  a  few  hours,  and  it  can  usually  be  relieved 
by  a  hot  bath  and,  if  necessary,  by  an  opiate.  At  the 
end  of  forty-eight  hours  a  larger  bougie  can  usually  be 
passed,  and  treatment  by  gradual  dilation  is  then  fairly 
begun.  If  the  stricture  is  somewhat  irritable,  is  com- 
plicated by  partial  or  complete  retention,  and  has  been 
entered  with  great  difficulty,  and  especially  if  the  ure- 
thra be  sensitive  to  instrumentation,  the  best  method  of 
treatment  is  by  continuous  dilation. 

Continuous  dilation  is  accomplished  as  follows  :  The 
first  filiform  bougie  that  passes  should  be  tied  in  and 
allowed  to  remain  for  twenty-four  hours.  After  a  few 
hours  the  stricture  dilates  and  allows  the  urine  to  pass 
beside  the  bougie,  so  that  retention  rarely  occurs.  At 
the  end  of  twenty-four  hours  the  dilation  is  usually 
considerable,  and  the  filiform  may  be  replaced  by  a 
bougie  a  size  or  two  larger,  which  may  be  tied  in  for 
another  twenty-four  hours.  Successive  sizes  may  thus 
be  used  for  a  few  days  until  the  stricture  will  admit  a 
No.  8  or  No.  10  bougie.  Further  dilation  is  best  ac- 
complished by  the  gradual  method.  The  chief  objection 
to  the  employment  of  continuous  dilation  is  that  it 
occasionally  results  in  cystitis  or  produces  urethral  fever. 
The  danger  can  be  lessened  greatly  by  using  all  anti- 
septic precautions,  including  irrigation  of  the  urethra, 
and  by  giving  full  doses  of  urotropin  or  boric  acid 
throughout  the  treatment.  The  new  bougie  or  catheter 
substituted  each  day  should  be  one  or  two  sizes  smaller 
than  the  largest  that  can  be  introduced.  An  instrument 
that  completely  fills  the  stricture  produces  more  pressure 
and  increases  the  danger  of  complications  without  pro- 
ducing more  rapid  dilation  than  one  a  size  or  two  smaller. 
Very  small  bougies,  on  the  other  hand,  may  easily  be 
washed  out  of  the  urethra  by  the  urine.  The  outer  end 
of  the  bougie  should  be  tied  with  two  or  three  pieces  of 


556      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

soft  cotton  twine  to  the  pubic  hairs.  If  these  pieces  of 
twine  are  also  fastened  to  opposite  points  of  a  ring  (large 
enough  to  permit  erection)  of  tape  encircling  the  penis  an 
inch  or  two  from  the  glans,  the  bougie  will  be  held  more 
securely.  Unless  some  means  be  employed  to  secure 
the  bougie,  it  may  slip  out  of  the  urethra,  or  it  may 
escape  backward  into  the  bladder  and  necessitate  an 
operation  for  its  removal. 

Continuous  dilation  should  not  be  employed  in 
patients  who  do  not  tolerate  well  the  presence  of  a 
bougie  in  the  urethra,  nor  in  patients  who  will  not  re- 
main in  bed  during  the  treatment.  It  should  be  sub- 
stituted by  some  other  method  if  it  is  attended  by 
decided  urethral  fever.  Slight  fever  and  chills  are  not 
sufficient  reason  for  suspending  treatment,  but  such  cases 
require  careful  and  constant  watching. 

When  continuous  dilation  is  not  applicable  to  a  given 
case,  the  first  filiform  bougie  passed  may  be  used  as  a 
guide  for  the  introduction  of  a  tunnelled  sound  or  a 
catheter.  The  method  has  already  been  described  in 
detail.  If  the  attempt  is  successful,  gradual  dilation 
may  follow.  If  the  tunnelled  sound  cannot  be  intro- 
duced, and  if  continuous  dilation  is  not  permissible, 
urethrotomy  must  be  performed. 

Indications  for  Urethrotomy. — Dilation,  as  previously 
described,  is  the  most  effective  as  well  as  the  safest 
method  of  treatment  in  most  cases  of  stricture ;  but 
cases  are  not  infrequent  which  refuse  to  yield  to  this 
method,  and  which  may  be  rendered  worse  by  at- 
tempting to  continue  it.  Treatment  by  internal  ure- 
throtomy when  the  stricture  is  located  in  the  pendulous 
urethra,  and  by  external  urethrotomy  or  by  the  com- 
bined method  for  stricture  of  the  deep  urethra,  is  neces- 
sary in  the  following  classes  :  i .  Strictures  of  the  meatus. 
2.  Cicatricial  and  traumatic  strictures  which  refuse  to 
yield  to  either  gradual  or  continuous  dilation.  3.  Re- 
silient strictures  which  rapidly  re-contract  after  dilation. 
4.  Strictures  in  which  attempts  at  dilation  are  followed 


ORGANIC  STRICTURE    OF   THE    URETHRA.        SS7 

by  marked  urethral  fever  and  chills.  5.  Strictures  com- 
plicated by  abscess,  fistulae,  extravasation,  or  other  con- 
ditions which  render  a  perineal  section  necessary,  the 
stricture  being  divided  at  the  same  operation.  6.  Stric- 
tures with  which  retention  is  complete  or  of  long  stand- 
ing, or  with  which  the  general  health  is  involved  and 
immediate  relief  is  necessary.  7.  Some  strictures  com- 
plicated by  an  enlarged  prostate.  8.  Strictures  in  indi- 
viduals who  cannot  give  the  time  necessary  for  treatment 
by  dilation. 

Many  operators  cut  all  strictures  of  the  pendulous 
urethra,  but  the  majority  of  surgeons  of  the  present  day 
cut  such  strictures  only  when  they  refuse  to  yield  to 
dilation.  The  cutting  operation  must  be  followed  by 
the  regular  use  of  the  sound  if  the  results  are  to  be  per- 
manent, and  internal  urethrotomy  is  attended  not  only 
by  some  danger  to  life,  but  also,  when  the  operation  is 
extensive,  by  danger  of  subsequent  deformity  of  the 
penis,  rendering  erections  imperfect  or  painful  and  inter- 
fering with  the  expulsive  power  of  the  urethra,  so  that 
micturitition  is  followed  by  dribbling  of  urine.  Many 
of  the  "  strictures  of  large  calibre  "  which  have  been 
reported  as  cured  by  internal  urethrotomy  alone  were 
undoubtedly  mere  normal  contractions  of  the  urethra. 
Cutting  should  be  reserved  for  those  strictures  to  which 
dilation  is  not  applicable. 

Meatotomy. — Strictures  at  the  meatus  or  just  within  it 
do  not  yield  to  dilation,  which  in  this  part  of  the  ure- 
thra is  painful  and  irritating.  Such  strictures  should  be 
cut.  Congenital  narrowing  of  the  meatus  does  not  call 
for  operation  unless  interfering  with  the  normal  func- 
tions of  the  urethra  and  productive  of  symptoms,  or 
unless  it  is  necessary  to  introduce  large  instruments  for 
treatment  of  the  deeper  portions  of  the  urethra.  Meatot- 
omy may  be  performed  with  a  straight  bistoury  or  with 
a  probe-pointed  tenotome  with  a  convex  edge.  The  in- 
cisions should  be  made  slowly  and  carefully,  upon  the 
floor  and  in  the  median  line,  until  the  tissue  forming  the 


558      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

stricture  has  been  divided  completely.  In  case  of  con- 
genital narrowing  the  opening,  in  order  to  allow  for  some 
contraction,  should  be  made  slightly  wider  than  it  is  ex- 
pected to  remain.  When  hemorrhage  occurs,  it  can  be 
controlled  by  pressure,  and,  if  necessary,  the  glans  may 
be  compressed  continuously  by  wrapping  around  it  several 
times  a  narrow  strip  of  rubber  plaster.  The  plaster  will 
have  to  be  removed  with  each  act  of  micturition,  but  the 
patient  can  easily  re-apply  it.  Beginning  the  second  day 
after  the  operation,  a  full-sized  sound  should  be  inserted 
once  a  day  until  healing  is  complete ;  reunion  of  cut  sur- 
faces is  thus  prevented.  Treatment  of  the  deeper  por- 
tions should,  if  possible,  be  suspended  during  this  period. 
Meatotomy  rarely  necessitates  confining  the  patient  to 
bed,  but  the  operation  calls  for  the  same  antiseptic  meas- 
ures as  any  other  internal  urethrotomy. 

Internal  Urethrotomy. — This  operation  should  be  lim- 
ited to  strictures  within  four  inches  of  the  meatus.  For 
strictures  of  the  bulbous  and  membranous  portions  ex- 
ternal urethrotomy  or  Harrison's  combined  internal  and 
external  operation  is  much  safer  than  the  internal  opera- 
tion. No  surgeon  should  perform  internal  urethrotomy 
of  the  deep  urethra  unless  he  is  prepared  to  follow  it,  if 
necessary,  with  the  external  operation. 

When  possible,  all  cutting  operations  upon  the  ure- 
thra should  be  preceded  by  several  days  or  a  week  of 
preparation.  The  general  health  must  be  considered,  and 
especially  the  condition  of  the  kidneys.  A  simple  diet 
that  will  supply  the  needs  of  the  individual  without  taxing 
his  powers  of  elimination  ;  exclusion  of  alcohol,  tobacco, 
and  coffee ;  large  quantities  of  water  or  other  bland 
drinks  between  meals,  together  with  tonics  and  laxa- 
tives, if  indicated,  are  measures  required  in  most  cases. 
Boric  acid  or  salol,  10  to  20  grains — or  urotropin,  3  to  8 
grains — four  times  a  day,  should  be  given  to  sterilize  the 
urine  and  greatly  lessen  the  danger  of  urethral  fever  and 
other  complications.  If  the  urine  contains  pus,  urotropin 
usually  gives  the  best  results,  clearing  the  urine  in  a  few 


ORGANIC  STRICTURE    OF   THE    URETHRA.        559 

days  and  thus  adding  greatly  to  the  safety  of  the  opera- 
tion. Daily  irrigation  of  the  urethra  with  mild  antiseptic 
solutions  is  also  desirable.  The  operation  should  be  im- 
mediately preceded  by  emptying  the  bladder,  by  thorough 
cleansing  with  antiseptic  solutions  of  the  meatus,  glans, 
and  penis,  and  by  irrigation  of  the  urethra  with  a  saturated 
solution  of  boric  acid  or  a  1  :  10,000  solution  of  bichloride 
of  mercury.  In  case  of  cystitis  the  bladder  also  should 
be  irrigated,  if  possible.  All  instruments  used  should  be 
absolutely  clean  and  sterile.  For  several  days  previous 
to  the  operation  instrumentation  of  the  urethra  should  be 
avoided,  to  the  end  that  urethral  irritation  may  be  reduced 
to  a  minimum.  Strictures  within  two  inches  of  the  meatus, 
requiring  but  slight  cutting,  may  be  operated  upon  with- 
out confining  the  patient  to  bed,  though  the  results  are 
better  and  there  is  less  danger  if  the  patient  remains  in 
bed  for  twenty-four  hours  before  and  after  the  operation. 
For  deeper  seated  strictures,  however,  and  for  those  re- 
quiring extensive  cutting  the  patient  should  be  prepared 
carefully  as  for  any  other  surgical  operation,  and  should 
remain  in  bed  for  at  least  two  or  three  days  after  its 
performance.  The  urethra  may  be  anaesthetized  by 
the  use  of  a  1  or  2  per  cent,  solution  of  cocaine,  but 
general  anaesthesia  is  preferable  unless  contraindicated 
by  the  patient's  condition. 

For  internal  urethrotomy  but  three  of  the  many  instru- 
ments recommended  for  the  purpose  need  be  mentioned. 


Fig.  51. — Gross's  modification  of  Civiale's  urethrotome. 

In  the  pendulous  urethra  all  incisions  should  be  above, 
in  the  roof,  and  in  the  median  line.  The  incision  can 
be  made  in  this  line  more  accurately  if  the  urethra  be 
put  on  the  stretch  by  pulling  the  penis  forward.  If  the 
stricture  will  admit  a  No.  5  (French)  bougie,  a  Civiale 
urethrotome,  or  Gross's  modification  of  the  instrument 
(Fig.  51),  which  has  an  acorn-shaped  head,  is  the  simplest 


560      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

instrument.  The  bulb  is  passed  through  the  stricture, 
the  blade  is  exposed  to  any  desired  extent  by  a 
mechanism  in  the  handle,  and  the  instrument  is  with- 
drawn sufficiently  to  cut  through  the  stricture  from  be- 
hind forward.  The  blade  is  then  sheathed  and  the  in- 
strument is  withdrawn  from  the  urethra.  A  steel  sound 
should  then  be  passed  through  the  cut  stricture,  but 
not  to  the  bladder,  in  order  to  ascertain  if  the  stricture 
be  divided  completely.  If  the  division  is  not  complete, 
the  urethrotome  may  again  be  introduced  and  the  strict- 
ure be  divided  thoroughly.  For  this  second  cutting  a 
dilating  urethrotome  is  usually  to  be  preferred.  After 
the  stricture  is  fully  divided  the  urethra,  and  then  the 
bladder,  should  be  irrigated  with  a  warm  boric  acid 
solution,  some  of  which  may  be  left  in  the  bladder  to 
dilute  the  next  urine  that  must  pass  over  the  cut  surface. 
If  the  cutting  has  been  at  all  extensive,  it  is  often  best 
to  tie  a  full-sized  soft  catheter  in  the  urethra  for  the  first 
twenty-four  or  forty-eight  hours.  The  eye  of  the  cathe- 
ter should  be  just  within  the  vesical  sphincter,  for  if  it 
lie  too  far  within  the  bladder,  the  latter  will  not  be 
drained  completely.  This  catheter  should  be  new  and 
thoroughly  sterilized  by  boiling.  Its  removal  should  be 
followed  by  irrigation  of  urethra  and  bladder.  Hemor- 
rhage, which  is  not  often  severe,  may  be  controlled  by 
winding  a  strip  of  rubber  plaster  about  the  glans,  as 
recommended  after  meatotomy.  Beginning  forty-eight 
hours  after  the  operation,  a  full-sized  steel  sound  should 
be  passed  through  the  stricture  a  few  times  at  intervals 
of  three  or  four  days,  and  then  at  longer  intervals,  as  in 
treatment  by  dilation.  To  render  the  result  permanent, 
it  is  usually  necessary  to  continue  the  occasional  use  of 
the  sound  in  the  same  manner  as  after  treatment  by 
dilation. 

When  strictures  of  a  calibre  larger  than  No.  18  or  20 
require  cutting,  the  Otis  urethrotome  (Fig.  52)  is  prob- 
ably the  best  instrument  in  use.  The  closed  instrument 
is  introduced  into  the  urethra  until  the  point  occupied 


ORGANIC  STRICTURE    OF   THE    URETHRA. 


56l 


by  the  knife  is  half  an  inch  behind  the  stricture.  By 
means  of  a  screw  in  the  handle  the  parallel  blades  are 
separated  until  the  stricture  is  put  fully  on  the  stretch ,' 
the  blade  is  then  withdrawn,  cutting  the  stricture  from 


Fig.  52. — Otis's  dilating  urethrotome  (Tiemann) 


behind  forward.     The  other  steps  in  the  operation  are 
described  above. 

The  Maisonneuve  urethrotome,  used  for  internal 
urethrotomy  in  the  deep  urethra,  is  probably  the 
best  instrument  for  this  purpose,  since  it  can  be 
attached  to  a  filiform  guide  and  thus  be  conducted 
through  a  stricture ;  but  this  operation  is  one  to  be 
avoided  if  possible,  unless  it  be  followed  by  perineal 
puncture  and  drainage  as  recommended  by  Harrison  in 
his  combined  operation.  Some  of  the  modifications  are 
superior  to  the  original  instrument  in  having  protecting 


Fig.  53.— Teevan's  modification  of  Maisonneuve's  urethrotome  with  guide  (Tiemann). 

sheaths  for  the  knife,  which  can  thus  be  made  to  cut  the 
stricture-tissue  without  damaging  the  rest  of  the  urethra, 
and  in  being  fitted  with  a  wire  stylet,  the  removal  of 
which  allows  the  escape  of  urine  if  the  instrument  has 
properly  entered  the  bladder,  the  danger  of  cutting  a  false 
passage  being  thus  obviated  (Fig.  53).  The  instrument  is 
of  occasional  service  in  the  anterior  urethra,  since,  by 
means  of  its  guide,  it  can  be  inserted  into  a  stricture  too 
narrow  to  admit  the  smallest  Civiale  urethrotome,  and 


562       SYPHILIS  AND    THE   VENEREAL   DISEASES. 

the  stricture  may  then  be  divided  partially  from  before 
backward.  For  this  purpose  the  knife  should  run  in  a 
groove  in  the  upper  surface,  in  order  to  make  the  incision 
in  the  roof  of  the  urethra.  As  in  all  urethrotomies, 
the  instrument  should  be  held  firmly  in  the  median 
line  and  the  penis  pulled  well  over  it  to  keep  the  ure- 
thra on  the  stretch.  The  opening  should  be  made 
large  enough  to  admit  a  dilating  urethrotome,  with 
which  the  stricture  may  be  completely  divided. 

The  indications  for  internal  urethrotomy  have  already 
been  considered.  This  operation  should  be  performed 
when  the  stricture  is  situated  within  four  inches  of  the 
meatus  and  cannot  properly  be  treated  by  dilation. 

External  urethrotomy  {external  perineal  urethrotomy, 
perineal  section)  becomes  necessary  when  stricture  of  the 
bulbous  or  membranous  urethra  is  not  amenable  to  treat- 
ment by  dilation,  or  when  complications  necessitate  the 
immediate  division  of  stricture.  The  operation  should 
always  be  preceded  by  an  attempt,  while  the  patient  is 
under  ether,  to  pass  a  full-sized  steel  sound,  in  order  that 
the  possible  mistake  of  cutting  a  mere  spasmodic  stric- 
ture may  be  avoided.  If  a  filiform  bougie  can  be  passed, 
it  is  used  as  a  guide  in  what  is  known  as  "  Syme's  opera- 
tion "  or  in  the  combined  method  of  Harrison;  but  when 
a  filiform  bougie  cannot  be  made  to  enter  the  bladder, 
the  much  more  difficult  procedure  of  external  perineal 
urethrotomy  without  a  guide  must  be  performed. 

The  preparation  of  the  patient  for  these  operations  is 
that  already  described  for  internal  urethrotomy,1  and  is 
of  the  greatest  importance.  The  hands  of  the  operator 
must  be  surgically  clean,  his  instruments  must  be 
properly  sterilized  and  put  in  sterile  solutions  or  gauze, 
and  there  must  be  an  abundance  of  light  and  time  for 
the  operation,  which  should  be  done  under  general 
anaesthesia. 

1.  External  Urethrotomy  with  a  Guide. — Syme's  Opera- 
tion.— The  patient  is  firmly  held  by  assistants  or  by  ap- 
1  See  page  558. 


ORGANIC  STRICTURE    OF   THE    URETHRA.        563 

paratus  in  the  lithotomy  position,  the  perineum  is  shaved, 
and  the  entire  region,  including  scrotum  and  penis,  made 
as  aseptic  as  possible.  Irrigation  of  the  anterior  urethra, 
and,  when  possible,  of  the  bladder,  should  be  practised  as 
in  internal  urethrotomy.  If  the  stricture  be  too  small  to 
admit  the  ready  passage  of  a  tunnelled  catheter  staff  (Fig. 
49),  a  filiform  should  first  be  passed  to  the  bladder  and 
used  as  a  guide  to  the  staff,  as  directed  on  page  555. 
The  staff  having  passed  the  stricture,  an  assistant  holds 
it  and  so  presses  upon  it  as  to  make  its  convex  curve 
bulge  in  the  perineum.  At  the  same  time  he  retracts 
the  scrotum.  With  the  left  index-finger  in  the  rectum 
the  operator  makes  an  incision  exactly  in  the  median 
line  of  the  perineum,  one  inch  in  front  of  the  anus,  cut- 
ting down  upon  the  urethra,  which  he  opens  over  the 
groove   of  the    staff,  and    usually    behind    the    stricture. 


Fig.  54. — Teak's  gorget. 

The  latter  is  then  divided  along  the  groove  of  the 
staff.  A  Teale's  probe  gorget  (Fig.  54)  is  passed 
into  the  bladder  through  the  divided  stricture,  and 
the  staff  withdrawn.  A  full-sized  sound  is  then  intro- 
duced through  the  meatus  over  the  gorget  to  the 
bladder,  to  demonstrate  the  existence  of  a  clear  pas- 
sage. It  is  further  advisable  to  explore  the  bladder 
with  the  index-finger  for  calculi,  and  for  the  purpose 
of  fully  stretching  and  dilating  the  prostatic  urethra  and 
thus  preventing  tenesmus,  which  sometimes  follows  the 
operation.  The  finger  should  also  explore  the  roof  of 
the  urethra  for  any  stricture  tissue  that  has  not  been 
thoroughly  divided.  If  such  tissue  be  found,  it  should 
be  divided  by  means  of  a  small  grooved  director  and  a 
narrow,  probe-pointed  bistoury.  Cutting  in  the  roof  of 
the  deep  urethra  must  be  done  cautiously,  and  should  not 
extend  deeper  than  necessary  for  fear  of  serious  hemor- 


564      SYPHILIS  AND    THE   VENEREAL    DISEASES. 

rhage.  A  large  (30  F.)  soft  perineal  tube  (Fig.  5  5 )  is  passed 
into  the  bladder  just  far  enough  to  drain  perfectly  and  is 
secured  firmly  in  place  by  carrying  a  silk  suture  through 
the  tube  and  through  both  sides  of  the  wound.  The 
bladder  is  irrigated  with  a  warm  boric  acid  solution, 
some  of  which  should  be  retained  in  the  bladder  by 
clamping  the  tube  until  the  latter  has  been  connected 
with  a  piece  of  rubber  tubing  terminating  beneath  the 
surface  of  some  antiseptic  fluid  contained  in  a  convenient 
receptacle.  The  entrance  of  air  to  the  bladder  is  thus 
prevented.  The  wound  is  lightly  packed  with  iodoform 
gauze,    the    edges    being    held    together  by  the    suture 


Fig.  55. — Perineal  tube. 


which  holds  the  draining  tube  in  place,  and  the  whole  is 
covered  with  gauze  and  a  T-bandage. 

After  the  second  or  third  day  the  tube  is  taken  out 
and  cleaned  once  in  two  or  three  days,  and  is  perma- 
nently removed  in  five  or  six  days  unless  there  be  cystitis 
or  other  indication  for  continuing-  the  drainage  longer. 
With  each  removal  of  the  drain,  the  bladder  and  urethra 
are  irrigated  and  a  sound  (22-24  F.)  passed  from  the 
meatus  to  the  bladder.  The  sound  is  passed  every  two 
or  three  days  while  the  perineal  wound  is  healing ;  after 
this,  at  longer  intervals,  the  size  of  the  sound  being 
gradually  increased  up  to  26  or  30  F.,  or  to  such  size  as 
the  operator  decides  to  be  normal  for  the  individual. 
The  subsequent  treatment  is  that  of  gradual  dilation. 
Both  operator  and  patient  should  understand  that  unless 
urethrotomy  is  followed  by  the  systematic  and  prolonged 
use  of  sounds,  there  will  probably  be  a  reformation  and 
contraction  of  the  stricture 

The  operation  described  above  may  be  modified  in 
some  details.     Drainage  is  frequently  accomplished  by  a 


ORGANIC  STRICTURE    OF  THE    URETHRA.        565 

soft  catheter1  instead  of  a  perineal  tube,  the  catheter 
being  retained  from  one  to  three  days.  Instead  of 
passing  a  small  sized  tunnelled  sound  through  the 
stricture,  a  larger  sound  may  be  passed  over  a  filiform 
to  the  face  of  the  stricture,  where  it  is  held  by  an 
assistant  as  described  above.  The  operator  cuts  down 
upon  the  sound,  opens  the  urethra  in  front  of  the  strict- 
ure, and  passes  a  fine  grooved  probe  by  the  side  of  the 
filiform.  The  latter  is  removed  and  the  probe  is  used 
as  a  guide  for  a  narrow  beaked  bistoury,  with  which  the 
stricture  is  divided. 

Though  the  operation  may  thus  be  modified  in  some 
of  its  details,  the  surgeon  must  always  bear  in  mind  the 
following  rules : 

1.  He  must  not  cut  down  upon  his  guide  until  he  is 
sure  the  latter  has  entered  the  bladder,  and  that  it  is 
not,  instead,  lodged  in  a  false  passage. 

2.  In  cutting,  he  must  not  deviate  from  the  median 
line  for  fear  of  serious  hemorrhage. 

3.  In  so  far  as  possible,  he  will  keep  the  edge  of  his 
knife  directed  anteriorly  to  avoid  danger  of  injuring  the 
posterior  layer  of  the  deep  perineal  fascia — an  accident 
that  may  be  followed  by  infiltration  of  urine  into  the 
deeper  tissues  of  the  pelvis. 

2.  Combined  Internal  and  External  Urethrotomy. — The 
patient  is  prepared  as  for  the  preceding  operation.  By 
internal  urethrotomy,  using  a  Maisonneuve's  urethro- 
tome, the  stricture  is  divided  sufficiently  to  admit  the 
passage  of  a  grooved  catheter  staff,  which  is  held  in 
position  by  an  assistant  as  in  the  preceding  operation. 
A  long,  straight  knife,  with  its  back  to  the  rectum,  is  in- 
troduced in  the  median  line,  an  inch  in  front  of  the  anus. 
The  point  of  the  knife  should  puncture  the  membranous 
urethra  over  the  groove  of  the  director.  The  opening 
is  then  enlarged  forward,  just  enough  to  allow  the  in- 
troduction of  the  index-finger.  If  the  tissue  over  the 
groove  be  not  all  divided,  a  knife  that  is  not  very  sharp 
1  See  page  536. 


566      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

may  be  passed  along  the  finger  and  the  division  com- 
pleted. When  with  the  tip  of  this  finger  the  operator 
finds  the  groove  of  the  staff  is  clear,  he  passes  a  probe- 
tipped  gorget  into  the  bladder  and  proceeds  as  in  Syme's 
operation,  with  digital  exploration,  irrigation,  perineal 
drainage,  and  subsequent  urethral  dilation. 

3.  External  Urethrotomy  without  a  Guide — After  the 
patient  is  fully  under  the  anaesthetic,  an  attempt  should 
be  made  to  pass  a  sound  to  the  bladder.  If  the  patient 
has  been  passing  urine  by  the  urethra,  it  is  rare  that  the 
surgeon  cannot,  by  patient  and  careful  effort,  pass  at 
least  a  filiform  to  the  bladder,  after  which  he  may  pro- 
ceed with  continuous  dilation  or  with  urethrotomy  with 
a  guide.  If  all  efforts  at  passing  a  filiform  fail,  he  must 
undertake  the  operation  without  a  guide.  For  this  he 
must  have  the  requisite  skill,  a  good  light,  and  plenty  of 
time,  as  the  operation  is  often  very  difficult  and  tedious, 
and  even  excellent  surgeons  sometimes  fail  to  perform  it 
successfully. 

The  patient  being  prepared  and  in  position  for  a  peri- 
neal section,  one  of  the  two  following  operations  may  be 
performed : 

a.  Wheelhouse's  Operation. — A  grooved  steel  staff 
with  a  blunt  hooked  extremity  (Fig.  56)  is  gently  passed 


-...■^.■^.n:.:.:..!^--—^- 


Fig.  56. — Wheelhouse's  staff. 

to  the  stricture  and  held  in  place  by  an  assistant.  The 
operator  cuts  down  upon  the  groove  of  the  staff  as  in 
the  preceding  perineal  operations  and  opens  the  urethra 
about  a  quarter  of  an  inch  in  front  of  the  stricture.  A 
long  silk  ligature  is  passed  through  the  wall  of  the  ure- 
thra on  either  side  of  the  incision  for  the  purpose  of 
keeping  the  latter  open  during  the  remainder  of  the  ope- 
ration. The  sound  is  now  carefully  withdrawn  until  the 
hooked  end  appears  in  the  wound,  and  the  shaft  is  rotated 


ORGANIC  STRICTURE    OF  THE    URETHRA.        $6? 

1 80  degrees,  so  that  the  blunt  hook,  or  knob,  may  be 
used  to  retract  the  upper  end  of  the  urethral  wound. 
With  the  wound  stretched  open  at  three  points,  the 
operator  searches  the  anterior  face  of  the  stricture  with 
a  fine  probe-pointed  director  for  an  opening  to  the  blad- 
der. In  the  majority  of  cases,  patient  search  will  find  the 
opening  and  the  director  can  be  passed  to  the  bladder. 
When  this  has  been  accomplished  the  tip  of  the  director 
is  freely  movable  and  is  not  held,  as  it  would  be  in  a 
false  passage.  The  other  steps  of  the  operation  differ 
in  no  way  from  perineal  section  with  a  guide.  If,  how- 
ever, the  guide  cannot  be  passed  to  the  bladder,  the 
surgeon  has  a  serious  and  difficult  task  before  him. 
Unless  he  prefers  to  do  retrograde  catheterization,  he  will 
have  to  continue  the  operation  by  a  careful  dissection  in 
the  median  line  until  he  has  completely  cut  through  the 
stricture.  The  left  index-finger  in  the  rectum  serves  as 
a  guide.  It  is  imperative  that  his  field  of  dissection  be 
well  lighted  and  thoroughly  and  constantly  sponged. 
The  urethra  is  lighter  in  color  than  the  surrounding 
parts,  this  difference  being  intensified  by  the  application 
of  very  hot  water.  The  expulsion  of  a  few  drops  of  urine 
by  pressure  upon  the  hypogastrium  may  aid  in  locating 
the  urethra. 

b.  Cock's  Operation. — This  is  a  yet  more  difficult 
operation  than  the  preceding,  and  is  undertaken  only  in 
those  cases  in  which  no  instrument  can  be  passed  through 
the  anterior  urethra.  A  thorough  and  practical  knowl- 
edge of  the  anatomy  of  the  region  is  essential.  The 
left  index-finger  is  introduced  into  the  rectum  and,  after 
carefully  locating  the  landmarks,  the  tip  is  kept  in  con- 
tact with  the  apex  of  the  prostate.  A  straight,  sharp- 
pointed  knife  is  pushed  steadily  into  the  perineum  m.  the 
median  line  an  inch  in  front  of  the  anus,  and  is  made  to 
cut  toward  the  finger  in  the  rectum  until  the  point  of 
the  knife  is  felt  close  to  the  apex  of  the  prostate.  By 
advancing  the  knife  a  trifle  deeper,  the  urethra  should  be 
opened  at  the  tip  of  the  prostate.     A  grooved  director  is 


568      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

now  passed,  and  the  stricture  divided,  explored,  irrigated, 
drained,  etc.,  as  in  the  operations  above  described. 

In  doing  this  operation  the  knife  should  not  be  with- 
drawn nor  its  direction  changed  until  the  urethra  has 
been  opened.  If  the  attempt  fails,  it  is  better  to  do  a 
suprapubic  operation. 

c.  Retrograde  Catheterization. — In  the  rare  cases  in 
which  the  urethra  cannot  be  found  in  the  perineal  opening) 
as  after  rupture  or  laceration  of  the  urethra,  a  suprapubic 
opening  large  enough  to  admit  the  finger  is  made  into 
the  bladder.  A  woven  catheter,  or  a  soft-gum  catheter 
with  a  stylet,  is  then  passed  through  the  opening  and 
guided  by  the  finger  in  the  bladder  into  the  vesical 
opening  of  the  urethra.  The  catheter  is  then  passed  on 
through  the  perineal  opening,  and  the  urethra  thus 
located.  The  stricture  may  then  be  cut  and  treated  as 
in  any  external  urethrotomy. 

Divulsion  and  rapid  dilation  of  stricture  in  the  deep 
urethra  are  practised  by  some  surgeons  when  the  patient 
will  not  consent  to  a  urethrotomy ;  but  they  are  danger- 
ous procedures,  since  they  leave  lacerated,  instead  of  in- 
cised, wounds. 

Urethrectomy  has  been  performed  with  apparent  success 
in  some  cases  of  densely  fibrous  strictures.  The  cut  ends 
of  the  urethra  are  sutured  together  over  a  catheter.  In 
a  few  instances  transplantation  of  mucous  membrane  has 
been  successfully  performed.  More  time  and  further  ob- 
servations are  necessary  to  determine  the  ultimate  results 
of  these  operations. 

Other  methods,  including  electrolysis,  have  been  rec- 
ommended and  employed  at  various  times  for  the  treat- 
ment of  stricture,  but  they  are  inferior  to  those  described. 

Complications  of  Stricture. — Retention. — When  re- 
tention occurs  suddenly,  it  is  largely  due  to  an  added 
inflammation  or  irritation  of  the  urethra,  and  can  usually 
be  relieved  promptly  by  the  use  of  the  hot  bath  or  by 
the  soft  catheter  in  the  manner  described  for  the  relief 
of  retention  in   gonorrhoea.     No  effort  should  be  spared 


ORGANIC  STRICTURE    OF   THE    URETHRA.        569 

to  make  the  operation  as  aseptic  as  possible,  as  the  ex- 
cessive congestion  of  the  membranes  makes  infection 
unusually  easy.  If  the  patient  is  seen  before  the  bladder 
is  much  distended,  an  opiate  may  overcome  spasm  and 
allow  the  bladder  to  empty  itself.  If  the  giving  of  nar- 
cotics is  followed  by  relief  of  pain  only,  the  surgeon 
must  redouble,  rather  than  relax,  his  vigilance  lest  the 
bladder  be  excessively  distended  or  even  ruptured.  A 
filiform  bougie  can  often  be  passed  when  attempts  with 
a  catheter  fail ;  if  the  bougie  be  left  in  the  stricture  for  a 
few  hours,  the  stricture  will  dilate  and  allow  the  urine  to 
escape.1  When  other  measures  fail,  an  aspirator  may  be 
used. 

The  suprapubic  region,  the  operator's  hands,  and  in- 
struments having  been  prepared  as  for  any  other  aseptic 
operation,  a  small  incision  is  made  through  the  integu- 
ment just  above  the  pubis.  The  needle  of  the  aspirator 
is  inserted  in  this  cut  and  pushed  downward  and  back- 
ward to  the  bladder.  If  the  bladder  be  greatly  dis- 
tended, it  is  safer,  even  in  recent  cases,  not  to  empty  it 
entirely.  In  withdrawing  the  needle,  suction  should  be 
continued  to  prevent  the  possible  escape  of  urine  into 
the  cellular  tissue. 

The  operation  is  a  simple  one  and  not  dangerous  if 
properly  done.  It  may  be  repeated  a  number  of  times 
if  necessary,  but  in  these  acute  cases  one  emptying  of 
the  bladder  usually  suffices  to  lessen  the  congestion 
about  the  vesical  neck  and  thus  relieve  the  retention. 

In  old  cases  of  tight  stricture  with  a  history  of  re- 
peated attacks  of  retention  or  of  gradually  increasing 
difficulty  in  emptying  the  bladder,  and  when  the 
stream  of  urine  is  very  small  at  best,  retention  is  a  more 
serious  matter.  In  these  cases  the  hot  bath,  an  opiate, 
and  even  an  anaesthetic,  should  .be  tried  but  these  meas- 
ures are  sometimes  ineffective.  If  possible,  a  filiform 
bougie  should  be  passed  through  the  stricture,  and  left 
there   as   in  continuous  dilation.     In   nearly  every  case 

1  See  Continuous  Dilation  of  Stricture. 


570      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

so  treated  the  urine  soon  dribbles  out  beside  the  bougie 
and  the  retention  is  relieved.  If  this  measure  should  not 
succeed,  it  may  be  best  to  perform  at  once  an  external 
urethrotomy.  If  a  bougie  cannot  be  passed,  it  is  proper 
to  relieve  the  bladder  by  aspiration  for  several  days,  if 
by  so  doing  the  instrument  can  eventually  be  made  to 
enter  the  bladder.  In  case  all  such  attempts  fail,  ex- 
ternal urethrotomy  without  a  guide  becomes  necessary. 
To  determine  the  best  method  of  proceeding  the  surgeon 
should  consider  carefully  the  character  of  the  stricture, 
the  experiences  of  the  patient  during  previous  attacks  of 
retention,  and  all  other  conditions  peculiar  to  the  case. 

The  possible  presence  of  prostatic  enlargement  should 
always  be  considered,  and  the  diagnosis  carefully  made 
considering  the  history  and  symptoms,  and  by  rectal  ex- 
amination. In  prostatic  enlargement  the  Mercier  coude  or 
bicoude  catheter  (Fig.  47)  can  often  be  made  to  enter  the 
bladder  when  the  soft  catheter  will  not  do  so.  An  Eng- 
lish or  other  soft  catheter,  having  a  wire  stylet,  is  often 
valuable.  The  stylet  should  stop  at  least  one  inch  short 
of  the  tip,  that  the  latter  may  be  soft  and  flexible. 

In  these  chronic  cases,  where  there  has  been  partial 
retention  for  some  time,  it  is  very  important  that  all  the 
urine  be  not  withdrawn  at  one  time,  for  fear  of  shock 
and  vesical  and  renal  hemorrhage.  If  the  urine  is  in- 
fected, the  bladder  may  be  emptied  two-thirds  and  a  few 
ounces  of  a  boric  acid  solution  injected.  This  mixture 
is  allowed  to  run  out,  and  more  boric  acid  solution  in- 
troduced. The  process  is  repeated  until  the  urine  comes 
away  clear,  the  bladder  being  at  no  time  more  than  two- 
thirds  emptied. 

False  Passages. — When  false  passages  exist  in  connec- 
tion with  stricture,  they  should  be  recognized,  located, 
and  avoided  during  treatment.  Such  passages  are 
usually  small  and  serve  to  entrap  the  ends  of  fine  instru- 
ments. If  the  directions  already  given  for  instrumenta- 
tion of  the  urethra,  and  especially  those  for  the  use  of 
filiform  bougies,  be  followed  carefully,  danger  of  dilating 


ORGANIC  STRICTURE    OF   THE    URETHRA.        $?I 

a  false  passage  will  be  avoided.  The  walls  of  old  false 
passages  that  have  been  kept  open  sometimes  undergo 
changes  similar  to  those  of  stricture,  and  therefore  will 
grip  an  instrument  after  the  manner  of  a  stricture.  The 
diagnosis  in  these  cases  is  difficult,  and  must  be  made 
with  great  care. 

False  passages  are  produced  most  frequently  by  the 
use  of  small  steel  instruments,  usually  during  an  attempt 
to  pass  the  instrument  from  the  bulbous  to  the  mem- 
branous urethra.  The  urethral  walls  in  front  of  a  simple 
stricture  and  in  the  course  of  a  tortuous  stricture  are 
often  so  thinned  and  softened  that  they  may  easily  be 
penetrated  by  a  small  steel  sound,  especially  if  force  be 
used.  When  a  surgeon  has  been  unfortunate  enough  to 
make  a  false  passage,  he  should  recognize  the  fact,  or  he 
will  continue  and  dilate  the  opening  instead  of  the 
stricture.  The  perforation  of  the  urethral  wall  by  the 
point  of  an  instrument  gives  the  hand  of  the  operator  a 
sensation  very  different  from  that  produced  when  the 
instrument  passes  through  a  strictured  point  in  the 
urethra.  The  instrument  is  obstructed  in  its  movements, 
but  is  not  gripped  as  when  it  has  entered  a  stricture. 
The  direction  of  the  handle  shows  that  the  point  is  not 
in  the  median  line,  and  if  the  handle  be  depressed,  it 
cannot  be  rotated  as  when  the  point  is  in  the  bladder. 
The  finger  on  the  perineum  or  in  the  rectum  will  prob- 
ably distinguish  the  point  of  the  instrument.  On  with- 
drawing the  latter  there  is  usually  considerable  hemor- 
rhage. 

The  treatment  of  a  recent  false  passage  consists  of 
rest,  boric  acid,  urotropin,  or  salol  internally,  hygiene, 
and  the  avoidance,  if  possible,  of  all  instrumentation  of 
the  urethra  for  two  or  three  weeks.  The  damaged  tissue 
usually  becomes  inflamed,  causing  a  discharge  of  blood 
and  pus  for  a  few  days,  but  under  favorable  circumstances 
the  wound  heals  in  two  or  three  weeks.  Urethral  fever, 
abscess,  fistula,  or  even*  extravasation  may  result. 

Urethral  Fever  {Urinary  Fever). — This  much-dreaded 


572      SYPHILIS  AND    THE   VENEREAL   DISEASES. 

complication  of  stricture  usually  finds  its  exciting  cause 
in  instrumentation  of  the  urethra.  In  some  instances  the 
urethral  fever  is  apparently  due  chiefly  to  shock  or  to  re- 
flex influences,  but  in  most  cases  it  is  undoubtedly  the 
result  of  an  acute  toxaemia  or  septic  infection.  The  ure- 
thra back  of  a  stricture  usually  contains  micro-organisms 
and  their  toxines  capable  of  rapid  absorption  if  the  mu- 
cous membrane  be  even  slightly  cut,  torn,  or  abraded, 
though  there  are  evidences  of  such  absorption  in  but  a 
small  minority  of  operations  on  stricture.  Those  cases 
in  which  nausea,  syncope,  or  a  chill  occurs  immediately 
after  the  insertion  of  an  instrument  into  the  urethra  are 
undoubtedly  due  to  nervous  influence,  and  may  result 
from  the  skilful  passage  of  a  smooth  sound  which  has 
produced  no  damage  to  the  mucous  membrane.  These 
instances  undoubtedly  differ  widely  from  cases  of  uri- 
nary fever  proper. 

Some  patients,  usually  those  having  damaged  kidneys, 
lesions  of  the  urethra  or  bladder,  or  septic  urine,  are 
peculiarly  susceptible  to  chills  and  fever,  which  in  a 
few  individuals  follow  every  attempt  at  urethral  in- 
strumentation. This  susceptibility  may  suddenly  de- 
velop during  the  treatment  of  a  stricture,  or  it  may 
as  suddenly  disappear.  Occasionally  this  complica- 
tion is  one  of  the  symptoms  of  a  stricture,  and  disap- 
pears when  the  latter  is  properly  treated.  It  occurs 
rarely  after  operations  on  the  meatus,  but  it  increases  in 
frequency  with  the  depth  of  the  injury  in  the  urethra, 
being  most  frequent  after  divulsion  or  internal  ure- 
throtomy of  the  deep  urethra.  In  cases  of  old  stricture, 
especially  if  complicated  by  bladder  or  kidney  disease, 
the  danger  of  a  fatal  termination  is  greatly  increased. 

The  symptoms  usually  appear  within  twenty-four 
hours  after  instrumentation,  frequently  following  the 
first  urination.  In  other  instances  symptoms  may  not 
appear  for  two  or  three  days.  In  typical  cases  there  is 
a  sharp  chill,  lasting  from  a  few  seconds  to  several  hours, 
followed  by  fever  of  irregular   duration,  ranging  from 


ORGANIC  STRICTURE    OF   THE    URETHRA.        573 

100°  to  105  °  F.,  and  terminating  in  more  or  less  profuse 
perspiration.  The  patient  may  be  well  in  forty-eight 
hours,  or  a  feeling  of  lassitude  and  malaise  may  remain 
for  a  few  days.  In  very  mild  cases  slight  chills  may  be 
the  only  symptoms  noticed  by  the  patient.  In  severe 
cases  the  chill  is  sudden  and  violent,  and  is  attended  by 
great  prostration.  The  skin  is  cold  and  livid,  and  there 
may  be  vomiting  and  profuse  diarrhcea.  Suppression  of 
urine,  uraemia,  and  death  may  occur  within  twenty-four  or 
forty-eight  hours.  In  yet  other  cases  slight  chills  and 
mild  fever  may  be  followed  by  all  the  symptoms  of 
septicaemia  or  of  pyaemia,  with  a  fatal  termination. 

The  first  chill  may  be  followed  by  others  without 
further  exciting  cause,  and  the  fever  may  continue  in  an 
intermittent  or  remittent  form.  In  these  cases  the  symp- 
toms do  not  conform  in  type  and  character  to  the  first 
attack,  but  vary  greatly.  Finally,  the  fever  may  become 
chronic,  and  may  simulate  malaria  except  that  the 
symptoms  are  more  irregular  and  the  disturbance  of 
digestion  and  the  impairment  of  nutrition  are  more 
marked.  The  persistent  forms  usually  occur  in  connec- 
tion with  disease  of  the  bladder  and  the  kidneys. 

The  treatment  is  chiefly  prophylactic.  The  directions 
already  given  for  urethral  instrumentation,  including 
skilful  and  gentle  manipulations,  antiseptic  precautions, 
and  urethral  hygiene,  should  be  followed  carefully.  Of 
special  value  in  this  respect  is  the  use  of  boric  acid  in 
doses  of  from  10  to  20  grains  four  times  a  day,  its  admin- 
istration being  begun  forty-eight  hours  before  operating 
and  being  continued  for  several  days.  In  the  case  of 
some  patients  a  chill  may  be  prevented  by  a  prolonged 
milk  diet  or  by  the  use  of  morphine  and  pilocarpine 
just  before  operating.  There  is  no  specific  treatment 
for  urethral  fever  after  its  development.  The  patient 
should  be  put  to  bed,  and  free  perspiration  should  be 
encouraged  by  the  use  of  blankets,  hot-water  bottles, 
hot  drinks,  and  in  some  cases  by  the  administration 
of  jaborandi.     If  the  urine  is  infected,  urotropin  should 


574      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

be  given  in  doses  of  from  5  to  8  grains,  four  times 
a  day.  Further  treatment  is  purely  symptomatic.  Car- 
diac, and  other  stimulants  and  tonics  are  indicated 
in  severe  cases.  Suppression  of  urine,  marked  albu- 
minuria, or  haematuria  may  call  for  dry  cupping  over 
the  kidneys,  hot  vapor  baths,  large  quantities  of  bland 
drinks,  digitalis,  etc. 

Fistula. — If  fistulae  are  small ,  they  frequently  close 
when  the  stricture  is  dilated.  If  they  are  larger  and 
remain  open,  they  should  be  treated  on  surgical  prin- 
ciples. 

Abscess  has  been  considered  in  connection  with  Peri- 
urethritis. When  complicating  stricture  of  the  deep 
urethra,  external  perineal  urethrotomy  is  usually  the  best 
treatment. 

Extravasation  of  urine,  if  at  all  extensive,  calls  for 
prompt  surgical  treatment  to  secure  free  drainage  and  to 
prevent  abscess,  gangrene,  and  extensive  sloughing  of 
tissue.  When  the  quantity  of  extravasated  urine  is  slight, 
involving  a  small  circumscribed  region,  is  not  enlarging, 
and  is  not  interfering  with  micturition,  incisions  are  not 
necessary.  In  such  cases  the  treatment  is  directed  mainly 
to  the  patient  and  to  the  stricture.  Absorption  of  the 
extravasated  fluid  may  be  encouraged  by  rest  and  by  the 
application  of  hot  fomentations. 


GONORRHOEA   IN   WOMEN. 


Gonorrhoea  in  women  has  not  been  studied  so  long 
or  so  carefully  as  has  the  same  disease  in  men.  There 
is  great  diversity  of  opinion  with  reference  to  the  fre- 
quency of  its  occurrence,  its  relation  to  other  forms  of 
inflammation  of  the  organs  involved,  and  the  site  of  in- 
oculation. Bumm  and  some  other  observers  believe  that 
gonococci  never  penetrate  the  vaginal  epithelium,  and 
that  when  found  in  a  vaginal  discharge  they  come  from 
the  cervix  or  body  of  the  uterus.  Other  observers  find 
that  a  vaginitis  frequently  is  the  first  evidence  of  gonor- 
rhceal  infection.  It  is  certain  that  in  the  acute  gonor- 
rhoea of  girls  and  young  women  vaginitis  is  usually 
the  most  prominent  symptom.  In  older  women,  and  es- 
pecially in  those  who  have  borne  children,  the  vagina  is 
less  easily  inflamed,  and  the  process  is  most  marked  in 
the  endometrium  of  the  neck  and  body  of  the  uterus  or 
in  the  urethra.  In  children  infected  as  the  result  of 
criminal  violence  or  by  contaminated  towels  or  other 
media,  vulvitis  or  vulvo-vaginitis  most  commonly  results. 
Practically  there  is  little  difference  whether  the  site  of  in- 
fection be  the  vulva,  the  urethra,  the  vagina,  or  the  uterine 
neck,  since  in  the  great  majority  of  acute  cases,  excepting 
those  of  vulvitis  in  young  children,  the  inflammation  ex- 
tends eventually  to  all  of  these  regions,  and  also  to  the 
uterus,  the  Fallopian  tubes,  the  ovaries,  and  the  peri- 
toneum. In  the  chronic  forms  the  disease  is  most  fre- 
quent in  the  vaginal  portion  of  the  neck  of  the  uterus,  in 
the  pelvic  organs,  in  the  urethra,  and  in  the  glands  of 
Bartholin. 

In  acute  gonorrhoea  of  women  the  etiology,  the  modes 
of  infection,  the  period  of  incubation,  the  development  of 

575 


576      SYPHILIS  AND    THE   VENEREAL  DISEASES. 

symptoms,  and  the  pathological  changes  are  similar  to 
those  belonging  to  the  disease  in  men,  though  the  symp- 
toms (except  those  of  pelvic  inflammation)  are  usually 
less  severe  and  of  shorter  duration. 

The  disease,  however,  has  a  yet  greater  tendency  than 
in  men  to  become  chronic.  The  extent  of  surface  involved 
and  the  inaccessibility  of  portions  of  it  favor  the  continua- 
tion of  the  process.  Furthermore,  Noeggerath  and  others 
have  demonstrated  that  many  cases  of  chronic  gonorrhceal 
inflammation  of  the  pelvic  organs  in  women  develop  insid- 
iously, and  are  never  preceded  by  the  acute  form  of  the 
disease.  Such  cases  are  found  frequently  in  young  mar- 
ried women  whose  husbands,  though  supposing  them- 
selves sound,  had  never  fully  recovered  from  an  old  gon- 
orrhoea or  a  chronic  gleet.  The  great  majority  of 
subacute  and  chronic  pelvic  disorders  for  which  women 
consult  the  gynecologist  originate  in  gonorrhceal  infec- 
tion. Another  important  feature  of  the  disorder  in  women 
is  its  tendency  to  remain  latent  for  long  periods  during 
which  no  evidences  of  the  disease  are  apparent  even  on 
careful  examination.  Such  a  latent  and  unsuspected  gon- 
orrhoea may  be  aroused  to  activity  by  slight  causes,  and 
may  prove  a  source  of  infection. 

Diagnosis. — The  symptoms  of  acute  gonorrhoea  in 
women  are  those  of  vaginitis,  urethritis,  vulvitis,  Bartho- 
linitis, and  endometritis  resulting  from  other  causes.  Fre- 
quently salpingitis,  ovaritis,  and  peritonitis  are  also  pres- 
ent. Full  descriptions  of  these  disorders  are  found  in 
the  text-books  on  gynecology.  Brief  consideration  is 
here  given  merely  to  the  main  points  in  a  differential 
diagnosis  between  the  gonorrhceal  and  the  non-gonor- 
rhoeal  forms  of  inflammation. 

General  Characteristics. — In  general,  gonorrhceal  in- 
flammation is  more  severe  in  type  than  other  forms  ;  it 
usually  begins  with  slight  symptoms,  which  rapidly  in- 
crease in  intensity  for  a  few  days,  remain  stationary  for 
about  a  week,  and  then  decline ;  it  rarely  remains  limited 
to  any  one  organ,  but  usually  extends  to  several ;  it  shows 


GONORRHOEA    IN   WOMEN.  577 

a  decided  tendency  to  persist  and  become  chronic  ;  there 
is  often  a  history  of  exposure  to  infection,  followed  by  a 
period  of  incubation  of  from  three  to  five  or  more  days ; 
and  the  discharges  show  the  presence  of  gonococci. 

Vaginitis. — This  condition  is  present  in  many  acute 
cases  of  gonorrhoea,  though  whether  any  single  attack 
be  a  true  gonorrhceal  infection  or  merely  a  severe 
catarrhal  inflammation  induced  by  irritating  discharges 
from  the  uterine  neck  or  from  the  urethra  it  is  dif- 
ficult to  decide.  Microscopical  examination  of  the 
vaginal  secretion  is  tedious  and  often  unsatisfactory, 
since  the  vagina  contains  many  micro-organisms,  in- 
cluding diplococci,  which  often  can  be  differentiated 
with  difficulty  from  gonococci.  Culture-tests  should 
be  employed  in  doubtful  cases,  but  often  give  negative 
results  which  cannot  be  taken  as  conclusive  evidence 
of  the  absence  of  gonorrhoea  until  repeated  tests  of  the 
secretion  from  the  cervix,  urethra,  and  vagina  give  the 
same  results.  Often  the  diagnosis  must  be  based  chiefly 
upon  the  presence  or  absence  of  the  general  character- 
istics of  gonorrhceal  inflammation,  including  the  in- 
volvement of  other  organs.  This  form  of  vaginitis, 
which  usually  lasts  for  three  or  four  weeks,  shows  a 
marked  tendency  to  relapse  with  succeeding  menstrua- 
tions and  other  sources  of  local  irritation,  and  to  persist 
either  as  diffuse  chronic  vaginitis  or  in  localized  patches 
of  congested,  swollen,  and  eroded  mucous  membrane. 

Urethritis. — This  condition  is  probably  present  in  the 
majority  of  cases  of  gonorrhoea,  and,  as  it  does  not  often 
occur  from  other  causes,  except  those  which  are  trau- 
matic, its  demonstration  furnishes  fairly  good  evidence 
of  gonorrhceal  infection.  Finger  thinks  urethritis  is 
present  in  practically  all  cases  of  recent  infection,  but 
many  observers  find  it  much  less  frequent.  It  is  usually 
a  mild  af  "ection,  and,  while  it  is  not  infrequently  followed 
by  cystitis,  it  rarely  results  in  disease  of  the  kidneys,  as 
in  men.  The  subjective  symptoms  may  be  so  slight  as 
to  pass  unnoticed,  or  there  may  be  decided  burning  and 

37 


578      SYPHILIS  AND    THE  VENEREAL   DISEASES. 

smarting  of  the  sensitive  swollen  membrane,  with  fre- 
quent and  painful  micturition,  but  the  inflammation  is 
very  rarely  so  intense  as  in  gonorrhoea  in  men. 

The  orifice  of  the  urethra  is  red  and  swollen,  and 
the  congested  mucous  membrane  may  protrude.  With 
a  finger  in  the  vagina  the  urethra  is  felt  as  a  firm,  tender 
cord,  and  if  the  patient  has  not  urinated  for  several  hours 
pus  may  be  squeezed  out  of  the  urethra.  If  such  pus, 
unmixed  with  secretions  from  the  vagina  or  the  vulva, 
contains  gonococci,  the  diagnosis  is  unmistakable.  Mi- 
croscopical and  culture  examinations  are  much  more 
readily  made  and  are  more  satisfactory  than  in  vaginitis. 
The  acute  symptoms  rarely  last  for  more  than  two  or 
three  weeks,  but  they  are  frequently  followed  by  a 
chronic  urethritis,  which  is  often  overlooked. 

Chronic  urethritis  in  women  presents  no  subjective 
sensations,  and  is  recognized  only  by  careful  examination. 
If  the  orifice  be  cleaned  carefully  and  pressure  be  made 
upon  the  urethra  from  behind  forward  when  the  patient 
has  not  urinated  for  several  hours,  there  can  usually  be 
expressed  a  drop  of  muco-pus  containing  gonococci. 
The  endoscope  may  often  be  used  to  advantage.  The 
many  follicles  of  the  urethra  may  be  involved,  thus  favor- 
ing the  continuation  of  the  disease.  Five  or  six  large 
follicles  near  the  orifice  are  of  especial  importance,  and 
should  be  examined  carefully,  as  the  inflammation  may 
be  limited  to  them.  Chronic  urethritis  in  women  is  more 
easily  cured  than  in  men,  but  is  quite  commonly  unrecog- 
nized and  untreated. 

Vulvitis. — In  adults  vulvitis  has  not  yet  been  demon- 
strated to  be  gonorrhceal  in  character.  The  inflammation 
simply  results  from  contact  of  the  surfaces  with  irritating 
discharges  from  the  vagina  and  the  urethra.  This  con- 
dition in  women  corresponds  with  balanitis  in  men.  In 
children,  however,  gonorrhceal  inflammation  of  the  vulva 
has  been  demonstrated,  though  these  cases  have  no  cha- 
racteristic features  that  will  serve  to  distinguish  them 
from  vulvitis  due  to  other  causes. 


GONORRHCEA   IN   WOMEN.  S79 

Bartholinitis.  —  Inflammation  of  the  vulvo-vaginal 
glands  finds  its  most  frequent  cause  in  gonorrhoea,  and 
when  due  to  such  infection  usually  runs  a  rapid  course 
and  terminates  in  suppuration.  An  acute  infection  is 
rarely,  if  ever,  limited  to  the  gland. 

Chronic  inflammation  of  these  glands  not  infrequently 
complicates  chronic  gonorrhoea,  and  may  survive  as  the 
sole  relic  of  the  original  disease.  The  affected  gland  is 
usually  recognized  as  a  firm,  painless  nodule;  its  duct 
is  dilated  and  reddened.  Pressure  on  the  gland  usually 
causes  the  escape  of  a  mucous  or  muco-purulent  dis- 
charge which  may  contain  gonococci  and  may  prove 
highly  infectious. 

Inflammation  of  the  Uterus  and  its  Appendages. — Endo- 
metritis of  the  uterine  neck  occurs  in  most  cases  of  acute 
gonorrhoea,  and  in  a  large  percentage  of  cases  the  disease 
extends  to  the  tubes,  the  ovaries,  and  the  peritoneum. 
The  origin  of  the  inflammation  in  these  organs  cannot 
be  determined  by  the  symptoms  alone,  but  is  recognized 
by  the  presence  of  other  evidences  of  gonorrhoea  and  by 
the  history.  That  the  gonococcus  is  an  active  factor  in 
the  production  of  these  pelvic  inflammations  is  apparent 
from  the  fact  that  this  micro-organism  has  been  found  in 
the  pus  of  pyosalpinx  and  in  the  epithelium  and  connec- 
tive tissue  of  the  Fallopian  tubes. 

In  chronic  gonorrhoea  the  inflammation  almost  always 
involves  the  pelvic  organs,  and  is  one  of  the  most  fre- 
quent causes  of  sterility  and  of  chronic  invalidism  in 
women. 

The  frequency  with  which  a  chronic  gonorrhceal  in- 
flammation may  remain  latent  and  confined  to  one  or 
more  follicles  of  the  urethra,  to  one  of  the  vulvo-vaginal 
glands,  or  to  the  cervix  or  body  of  the  uterus  readily 
explains  why  a  man  may  be  infected  from  coitus  with  a 
woman  who  shows  no  signs  of  the  disease,  and  also  why 
he  may  have  intercourse  with  her  many  times  before 
coming  in  contact  with  the  gonorrhceal  virus. 

Treatment. — Hygienic  treatment,  which  is  always  of 


580      SYPHILIS  AND    THE  VENEREAL  DISEASES. 

great  importance,  is  practically  that  of  gonorrhoea  in 
men.  Rest,  a  light  diet,  diluent  drinks,  saline  laxatives, 
and  frequent  washing  of  the  external  genitals  should 
be  secured.  If  urethritis  is  present,  and  micturition  is 
painful,  alkalies  and  the  balsams  should  be  given.  All 
discharges  should  be  caught  on  pads  of  cotton  held  in 
position  by  a  bandage,  and  these  pads  should  be  burned 
when  soiled.  Hot  sitz-baths,  rest,  and  the  application 
of  cold  or  heat,  as  is  most  grateful,  to  the  perineal  and 
pubic  regions  is  of  value.  As  soon  as  the  patient  can 
tolerate  it,  the  vagina  should  be  irrigated  thoroughly 
twice  daily  with  hot  solutions  of  boric  acid,  or  of  potas- 
sium permanganate  (1  :  4000  to  1  :  1000).  The  external 
parts  should  be  kept  clean,  dusted  with  a  simple  powder, 
and  covered  with  thin  layers  of  cotton  or  lint  to  prevent 
contact  of  surfaces.  These  measures  will  obviate  the 
danger  of  vulvitis  and  will  add  to  the  patient's  comfort. 
If  vulvitis  occur,  slightly  astringent  lotions  or  powders 
may  be  used  in  addition. 

As  the  inflammation  subsides  it  is  well  to  irrigate 
with  a  solution  containing  nitrate  of  silver  (1  :  500  to 
1  :  100)  or  permanganate  of  potassium  (1  :  1000  to  I  : 
500) ;  or  somewhat  stronger  solutions  may  be  applied 
with  a  brush  or  a  cotton  swab.  The  cervical  canal 
should  be  kept  clean  and  should  receive  a  daily  applica- 
tion of  a  solution  of  nitrate  of  silver  (oSS— 3j  ad  fsj). 
Following  these  astringent  applications  the  vagina  may 
be  tamponed  with  cotton  soaked  in  iodoform  glycerin, 
borated  glycerin,  or  glycerite  of  tannin. 

If  the  urethritis  tend  to  become  chronic,  injections 
such  as  those  recommended  for  use  in  subacute  gonor- 
rhoea in  men  may  be  used,  the  bladder  always  being 
moderately  full.  Later,  solutions  of  nitrate  of  silver  in 
gradually  increasing  strength  may  be  applied  through 
an  endoscopic  tube.  If  the  follicles  are  involved,  they 
should  be  destroyed  with  the  fine  point  of  a  Paquelin 
cautery,  or  with  caustic  or  acid. 

Acute  Bartholinitis  should  be  treated  by  rest  and  by 


GONORRHOEA   IN   WOMEN.  58 1 

hot  local  applications.  If  suppuration  occur,  the  abscess 
should  be  opened  and  treated  on  surgical  principles.  In 
chronic  Bartholinitis  the  gland  should  be  enucleated  or 
be  destroyed  by  the  cautery. 

The  treatment  of  gonorrhceal  inflammation  of  the 
uterus  and  its  appendages  should  be  left  to  the  skilled 
gynecologist. 


INDEX. 


Absence  of  subjective  sensations  in 

syphilis,  76 
Accidents    and    injuries   in   syphilis, 

72 
"Acclimatization,"  350 
Acquired  syphilis,  25 

infantile,  270 
Adenitis,  gonorrhceal,  478 
Adenopathy  of  syphilis,  29 
syphilitic,  53 
primary,  303 
Adrenals  in  hereditary  syphilis,  217 
Alcohol  in  syphilis,  221 
Alopecia,  syphilitic,  treatment,  255 
with  structural  changes,  130 
without       obvious       structural 
change,  129 
syphilitica,  diagnosis,  131 
Aneurysm,  syphilitic,  1 63 
Annular  chancre,  34 
Ano-rectal  syphiloma,  169 
Antiquity  of  venereal  diseases,  20 
Anus  in  hereditary  syphilis,  217 

syphilis  of,  167 
Aponeuroses,  syphilis  of,  159 
Ardor  urinse,  355,  382 
Argyll-Robertson  pupil  in    diagnosis 

of  tabes,  183 
Arterio-sclerosis,  162 
Atrophic     tubercular     syphiloderm, 

no 
Atrophy,  acute  yellow,  of  liver,  167 
of  optic  nerve,  194 

"  Bad  disorder,"  25 
Balanitis,  43,  312 

diagnosis,  304,  313 

etiology,  312 

symptoms,  312 

treatment,  313 
Balano-posthitis,  312 

infective,  34 
Bartholinitis,  gonorrhceal,  579 
Bastard  gonorrhoea,  351,  359 

diagnostic  table,  365 
Bathing,  222 


Benignant  syphilis,  60,  61 
Bestiality,  334 
Blennorrhagia,  340 
Blennorrhagie,  340 
Blennorrhcea,  340 
Blood  in  syphilis,  26 
Blood-vessels,  syphilis  of,  162 
"  Blue-ball,"  293 

Bones   in    hereditary    syphilis,  209, 
218 

in  syphilis,  71 
treatment,  259 

syphilis  of,  152 
Borolyptol  in   treatment   of  mouth- 
syphilis,  257 
Boubon,  293 
Bougie  a  boule,  534 
Bougies,  bulbous,  534 

flexible,  535 

soft,  535 
Brain,  syphilis  of,  180 
Bronchi  in  hereditary  syphilis,  214 

syphilis  of,  151 
Bubo,  etiology,  296 

gonorrhceal,  478 

"  mixed,"  54 

of  chancre,  54 
diagnosis,  303 

of  chancroid,  293 

syphilitic,  29,  53 
treatment,  56 
Bulbous  bougies,  534 
Bursse,  syphilis  of,  158 

Cachexia,  syphilitic,  69 
Calcareous  lesions  of  hereditary  syph- 
ilis, 202 
Calibre  of  the  urethra,  547 
Care  of  instruments,  541 
Catarrh  of  middle  ear,  196 
Catheterism  of  the  urethra,  526 
Catheterization,  retrograde,  568 
Catheters,  silver,  535 

soft,  536 
Central  recurrent  retinitis,  193 
Cerebro-spinal  syphilis,  184 

583 


5§4 


INDEX. 


Cervix   uteri,  exulcerative   hypertro- 
phy of,  177 
Chancre,  28 

annular,  34 

deeply  ulcerating,  33 

diagnosis,  42,  300 

diffuse  infiltrating,  34 

duration  of,  41 

extra-genital,  37 

follicular,  ^ 

hard,  28 

Hunterian,  33 

incrusted,  33 

indurated  nodule,  34 

infecting,  28 

in  women,  37 

location,  36 

"  mixed,"  33,  289 

multiple  herpetiform,  33 

pathological  anatomy,  47 

rare  types  of,  ^ 

relapsing,  40 

silver  spot,  ^ 

soft,  34 

superficially  ulcerating,  32 

termination  of,  41 

treatment,  48 

urethral,  36 

vaginal,  37 
Chancre  niou,  279 
Chancre  redux,  40 
Chancre  syphilitique,  28 
Chancrelle,  33,  279 
Chancres,  induration  of,  38 

number,  38 

of  the  syphilized,  35 

portent  of,  40 

within  the  nares,  146 
Chancroid,  33,  42,  279 

adenopathy,  293 

and  paraphimosis,  290 

and  phagedena,  291 

and  phimosis,  290 

auto-inoculabilitv      of      secretion, 
287 

complications,  289 

diagnosis,  297,  300 

duration,  285 

erosive  lesion,  283 

etiology,  280 

extra-genital,  289 

gangrene,  292 

incubation,  286 

induration,  absent,  287 

lesions,  282 

location,  288 

lymphadenitis,  293 

lymphangitis,  293 


Chancroid,  number  of,  284 
pustular  lesion,  283 
size,  285 

subjective  sensations,  287 
treatment,  298 
variations,  284 
with  vegetations,  290 
Chancroidal  bubo,  293 
diagnosis,  302 
etiology,  296 
treatment,  309 
Chandepisse,  340 

Chemical  causes  of  urethritis,  349 
Chordee,  356 

treatment,  383 
Chorio-retinitis,  192 
Cicatrices  from  gummata,  120 
Ciliary  body,  syphilis  of,  191 
Clap,  340 

Classification  of  syphilodermata,  81 
Cock's  operation,  567 
Cold  sound  in  urethritis,  434 
Colles's  law,  197,  198 
Color  in  syphilodermata,  75 
Color-test  for  shreds  in  urine,  415 
Complications  cf  urethritis,  442 
Condensing  osteitis,  154 
Condyloma,  44,  99 
Condylomata  in  hereditary  syphilids, 
204 
lata,  99 
Congenital  syphilis,  197 
Conjunctiva,  syphilis  of,  1 88 
Conjunctivitis,  gonorrhoeal,  487 
diagnosis,  490 
etiology,  488 
pathology,  490 
prognosis,  495 
symptoms,  488 
treatment,  491 
Continuous  immersion  in  chancroids, 

308 
Copaiba-rash,  377 
"  Copper  color,"  75 
Cord,  syphilis  of,  182 
Cornea,  syphilis  of,  188 
Corneous  syphiloderm,  96 
Corona  veneris,  90 
Corymbiform  syphiloderm,  93 
Cowperitis,  477 

Cranial  bones  in  hereditary  syphilis, 
218 
meninges,  syphilis  of,  180 
Crystalline  lens,  syphilis  of,  192 
Curve  of  the  urethra,  524 
Cystitis,  gonorrhoeal,  469 
causes,  469 
diagnosis,  470 


INDEX. 


585 


Cystitis,  gonorrhoea!,  symptoms,  469 
treatment,  472 

Dactylitis,  syphilitic,  156 

hereditary,  212 
"  Defective  memory,"  328 
Delire  des  grandeurs,  185 
Dementia  paralytica,  184,  185 
Diagnosis  of  chancre,  300 

of  chancroid,  300 
Diffuse  infiltrating  chancre,  34 
Disinclination  for  society,  328 
Dreams,  328 

"Dry"  tubercular  syphiloderm,  no 
Ducrey,  micro-organism  of,  in  chan- 
croid, 296 

Ear  in  hereditary  syphilis,  220 
in  syphilis,  treatment,  264 
syphilis  of,  195 

Eburnation,  154 

Eczema  of  genital  region,  diagnosis, 

Einfacher  Schanker,  279 
Endarteritis  obliterans,  162 
Endoscope  in  urethritis,  417 
Endoscopic  urethral  instruments  and 

methods,  417 
Epididymis,  syphilis  of,  173 
Epididymitis,  acute,  442 
symptoms,  446 
treatment,  455 

chronic,  symptoms,  447 
treatment,  455 

diagnosis,  447 

etiology,  442 

frequency,  442 

prognosis,  455 

relapses,  446 

strapping  the  testicle  in,  453 

symptoms,  443 

syphilitic,  treatment,  261 

treatment,  448 
Epiphysary  exostoses,  155 
Epithelioma,  genital,  45 

of  genital  region,  304 
Erosion,  31 

superficial,  31 
Erotomania,  334 
Erythematous  syphiloderm,  83 
Esthio77iene,   168,  292 

of  Huguier,  175 
Evolution  of  syphilis  after  chancre, 

65 

of  syphilodermata,  76 
Excursions  of  syphilis,  57 
Exostoses,  epiphysary,  155 

parenchymatous,  155 


Exostoses,  syphilitic,  155 
External  urethrotomy,  with  a  guide, 
562 

without  a  guide,  566 
Extravasation  of  urine  due  to  strict- 
ure, 521,  574 
Eye  in  hereditary  syphilis,  219 
in  syphilis,  treatment,  263 
syphilis  of,  186 
Eyelids,  syphilis  of,  187 

Failure  of  erection,  332 
Family,  the,  and  syphilis,  271 
Fever,  syphilitic,  66 

urethral,  531 
Fibrosis  of  kidney,  177 
Filiform  bougies,  536 

introduction  of,  538 
Finger,  syphilitic,  156 
Fistula,  574 

of  the  urethra  due  to  stricture,  521 
Flexible  and  steel  instruments  com- 
pared, 539 

bougies,  535 
Follicular  chancre,  33 
Formative  osteitis,  154 
Fractures    in    bone-syphilis,  heredi- 
tary, 2 1 1 
Frequency  of  micturiiton  in  stricture, 

.5l6 
Fumigation  with  mercury,  235 

Furuncular     lesions    in     hereditary 

syphilis,  204 

Galloping  syphilis,  59 
Gangrene  and  chancroid,  292 
Gastro-intestinal  tract,  syphilis  of,  165 
Gauge,  Handerson's,  534 
General  considerations,  etc.,  relative 

to  syphilodermata,  79 
Genital  organs  in  hereditary  syphilis, 

208 
Genito-urinary    organs,    syphilis    of, 
172 
in  men,  172 
in  women,  175 
Glands,  lymphatic,  67 
Gleet,  340,  402 

due  to  stricture,  518 
Glossite  tonsurante,  141 
Glycosuria  in  syphilis,  178 
Gomme  scrofuleuse,  122 
Gonococcus,  341 
characters,  344 
culture  of,  345 
etiological    factor    in    gonorrhoea, 

cause  of,  341 
in  chronic  urethritis,  405,  408,  409 


586 


INDEX. 


Gonococcus,  preparation    of    speci- 
men, 342,  366 
toxines,  347 

value  in  diagnosis,  345,  366 
Gonorrhee,  340 
Gonorrhoe,  340 
Gonorrhoea,  acute,  33S 
bastard,  351,  359,  365 
cause   of  pelvic    inflammation    in 

women,  410 
chordee  in,  356 
chronic,  402 
complications,  442 
adenitis,  478 
conjunctivitis,  4S7 
Cowperitis,  477 
cystitis,  469 
epididymitis,  442 
folliculitis,  474 
infection  of  mouth  and  rectum, 

497 

lymphangitis,  478 

ophthalmia  neonatorum,  495 

periurethritis,  475 

posterior  urethritis,  397 

prostatitis,  456 

pyelitis,  472 

rheumatism,  479 

vesiculitis,  467 
definition,  340 
diagnosis,  362 

differential,  363 

examination  of  patient,  362 
diagnostic  table,  365 

value  of  gonococcus,  345 
differential  diagnosis,  363 
epididymitis  from,  442 
examination  of  discharge,  366 
folliculitis  in,  474 
in  women,  575 

diagnosis,  576 

treatment,  580 

unrecognized,  579 
lymphangitis  in,  356 
microscopical  examination  of  dis- 
charge, 366 
most  venereal  of  diseases,  340 
pathology,  360 
prognosis,  395 
relapse,  357 
sexual  hygiene,  373 
stationary  stage,  357 

variations  in,  357 
symptoms,  constitutional,  359 

increasing  stage,  354 

prodromal  stage,  353 

stage  of  decline,  357 
of  incubation,  353 


Gonorrhoea,  table  of  differential  diag- 
nosis, 365 
treatment,  367 
abortive,  368 
by  stages,  381 
dressing  for  penis,  374 
general  conditions,  368 
hygiene,  371 
beverages,  373 
diet,  373 
dressings,  374 
rest,  372 

sexual  hygiene,  373 
tobacco,  373 
injections,  391 
internal,  376 
irrigation,  394 
local,  384,  391 
of  chordee,  383 
of  retention  of  urine,  383 
of  sexual  irritation,  383 
prophylaxis,  367 
suspensory  bandages,  376 
unrecognized,  352 
Gonorrhceal  conjunctivitis,  487 
rheumatic  ophthalmia,  484,  490 
rheumatism,  479 
diagnosis,  4S5 
etiology,  479 
of  bursa;,  483 
of  synovial  sheaths,  483 
ophthalmic  symptoms,  483 
pathology,  484 
prognosis,  487 
symptoms,  480 
treatment,  486 
varieties,  480 
Gram's  method  of  staining  the  gono- 
coccus, 343 
"  Ground-glass  "  cornea,  220 
Gumma,  1 18 
Gummata  of  mouth,  142 
of  rectum,  169 
treatment,  261 
Gummatous  fibrosis  of  lung,  164 
iritis,  190 
syphiloderm,  118 
diagnosis,  122 
pathology,   124 

Hair,   syphilitic    affections   of   the, 

128 
Hairs  in  hereditary  syphilis,  208 
Handerson's  gauge,  534 
Hard  chancre,  28 
Hartes  Geschwilr,  28 
Heart,  aneurysm  of,  1 61 
syphilis  of,  1 60 


INDEX. 


587 


Hemiatrophy  of   tongue  in  syphilis, 

144 
Hemorrhagic  syphilis,  220 
Herpes  progenitalis,  43,  323 
diagnosis,  303,  325 
symptoms,  323 
treatment,  325 
History  of  venereal  diseases,  20 
Hunterian  chancre,  33 
Husband,  infected,  272 
Hutchinson's  teeth,  212 
Hydrargyrism,  241 
Hygiene  of  syphilis,  221 

of  urethra,  371 
Hyperostoses  of  tibia,  210 
Hypertrophy,  exulcerative,  of  cervix 

uteri,  177 
Hypochondriasis,  326 

treatment,  336 
Hypodermatic  injection  of  mercury, 
237 

Immunity   against    syphilitic  infec- 
tion, 27 
"  Impotence,"  328,  333 
Incrusted  chancre,  33 
Incubation  of  chancre,  first,  28 
second,  67 
of  chancroid,  286 
Indurated  nodule,  34 

papule,  32 
Induration,  lymphatic,  treatment,  56 
Infantile  syphilis,  acquired,  270 
Infecting  chancre,  28 
Infection  of  husband,  272 
of  physicians,  1 8 
of  wife,  272 
Infectious  urethritis,  340 
Infective  balano-posthitis,  34 
Infiltration  of  urine,  521 
Inherited  syphilis,  196 
Initial  lesion,  28 
sclerosis,  28 
diagnosis,  300 
Injection  of  chancroidal  buboes,  310 
of  deep  urethra,  435 
of  mercury,  hypodermatic,  237 
Injections  in  gonorrhoea,  391 

in  urethritis,  528 
Injuries  and  accidents  in  syphilis,  72 
Insoluble  salts  of  mercury  for  injec- 
tion, 240 
Instrumentation  of  the  urethra,  524 
indications  for,  543 
preparation  for,  532 
urethral  spasm  in,  503 
with  flexible  instruments,  538 
Instruments,  care  of,  541 


Instruments,  list  of  those  needed,  542 

urethral,  533 
Insurance  of  the  infected,  276 
Internal  urethrotomy,  558 
Interstitial  keratitis,  188 
Intestinal  tract  in    hereditary  syph- 
ilis, 215 
Introduction,  17 
Inunction  of  mercury,  231 
Iodides  in  hereditary  syphilis,  267 
Iodine  and  its  compounds,  243 

compounds,  toxic  effects,  247 
Iris,  syphilis  of,  189 
Iritis,  gummatous,  190 

parenchymatous,  190 

serous,  190 

syphilitic,  treatment,  263 
Irrigation  in  gonorrhoea,  394 

of  urethra,  414,  428 

Jaundice  in  syphilis,  70,  166 
"Jock-strap"  in  treatment  of  chancre, 

5° 
Joints,  syphilis  of,  157 

Keratitis,  interstitial,  188 
Keyes-Ultzmann  syringe,  435 
Kidney,  syphilis  of,  jo,  177 
Kidneys  in  hereditary  syphilis,  217 
Kiefer's    urethral    irrigation    nozzle, 

4S6 
Kra7ikheit  der  Franzosen,  25 

Labyrinth  in  syphilis,  196 
Labyrinthitis  of  hereditary  syphilis, 

220 
Lachrymal  gland,  syphilis  of,  186 
Languettes,  I"J2,  1 75 
Larynx  in  hereditary  syphilis,  214 
syphilis  of,  148 

prognosis,  15 1 
Lassar  paste,  235 
La  syphilide  papillomateuse,  112 
Latent  gonorrhoea  in  women,  579 
Legal  sanction  of  prostitution,  276 
Leptomeningitis,  218 
Lesions  of  chancroid,  282 
Leucokeratosis,  lingual,  141 
Leucoma  buccae,  141 
Leucoplasia  of  the  mouth,  141 

diagnosis,  144 

pathology,  145 
Lichen  planus,  genital,  46 
Life-assurance  societies  and  syphilis, 

276 
"Lightning"  symptoms,  63 
Lipoma,  122 
"  Listerine,"  256 


5' 


INDEX. 


Liver,  acute  yellow  atrophy  of,  167 

in  hereditary  syphilis,  216 

syphilis  of,  165 
Loss  of  memory,  332 
"Losses  at  stool,"  329 
"  Lost  manhood,"  328,  332 
Lues  venerea,  25 
Lung,  gummatous  fibrosis  of,  164 
Lungs  in  hereditary  syphilis,  215 

syphilis  of,  163 
Lung-syphilis,  diagnosis  of,  164 
Lupoma,  122 
Lupus  of  the  vulva,  16S 
Lustseuche,  25 

Lymphadenitis  and  chancroid,  393 
Lymphangitis  and  chancroid,  393 

indurata,  55 

in  gonorrhoea,  356 

syphilitic,  53 
Lymphatic  glands,  67 

in  hereditary  syphilis,  208 

induration,  treatment,  56 

Macular  syphilis  of  mouth,  138 

syphiloderm,  anatomy,  88 
diagnosis,  88 

syphilodermata,  81 
Malignant  syphilis,  61,  62 
Mammalia,  sexual  relations  of,  326 
"  Marmoraceous  "  syphiloderm,  82 
Marriage  after  syphilis,  274 
Masochism,  334 
Masturbation,  327 
"  McDade  formula,"  247 
Meatotomy,  433,  557 

indications  for,  546 

results  of,  546 
Mechanical  causes  of  urethritis,  349 
Melanotic  whitlow,  157 
Membrana  tympani,  195 
Meninges,  syphilis  of,  182 
Mental  states  due  to  syphilis,  184 
Mercier  catheter,  536 
Mercurial    inunctions    in    hereditary 
syphilis,  268 

pains,  241 
Mercury  by  fumigation,  235 

by  injection,  237 

by  inunction,  231 

in  syphilis,  226 

toxic  effects  of,  41 
Method  of  examining  patients,  21 
Miliary  papules,  90 

pustular  syphiloderm,  103 
"  Mixed  "  bubo,  54 

chancre,  33,  289 

treatment,  249 
Modes  of  infection  in  syphilis,  26 


Moist  papule,  98,  138 
diagnosis,  101 

wart,  44,  99 
Molluscum  epitheliale,  45 
Monti's  formula,  267 
Morbus  gallicus,  25 
Mouth,  gummata  of,  142 

leucoplasia  of,  14 1 

macular  syphilis  of,  138 

smoker's  patches  of,  141 

syphilis  of,  136 
Mucous    membranes    in    hereditary 
syphilis,  205 

patches,  98,  140 

plaques,  98 

tubercle,  138 
Multiformity  in  syphilis,  75 
Multiple  cerebro-spinal  syphilis,  184 

herpetiform  chancre,  33 
Muscse  volitantes,  332 
Muscles,  syphilis  of,  159 
Myositis,  159 

progressive  ossifying,  160 

Nail,  changes  in,  134 
atrophic,  134 
hypertrophic,  134 
in  tissues  surrounding,  132 
separation  of,  1 35 
syphilis  of,  diagnosis,  136 
syphilitic  affections  of,  132 
Nails  in  hereditary  syphilis,  207 

syphilitic,  treatment,  259 
Nasal  passages  in  hereditary  syphilis, 

212 

syphilis  of,  146 
Naso-pharynx  in  syphilis,  treatment 

264 
Nervous  syphilis,  treatment,  262 

system,  syphilis  of,  179 
Night  losses,  328 
Nocturnal  emissions,  328 

pains,  152 
Nodes,  153 
Nodule,  indurated,  34 
Non-infecting  chancre,  279 
Non-infectious  urethritis,  348 

etiology,  348 
Non-ulcerative    tubercular    syphilo- 
derm, 1 10 
Nummular  syphiloderm,  93 

Ocular  appendages,  syphilis  of,  186 

muscles,  syphilis  of,  194 
Oculo-motor  paralyses,  182 
Oculo-motorius,  paralysis  of,  182 
(Esophagus    in    hereditary    syphilis 
215 


INDEX. 


589 


Onychauxis,  syphilitic,  134 
Onychia  syphilitica,  134 
Ophthalmia,    gonorrhceal  rheumatic, 
484,  490 

neonatorum,  495 
Optic  nerve,  atrophy  of,  194 

syphilis  of,  193 
Orbit,  syphilis  of,  194 
Orchitis,  syphilitic,  173 
Osteitis,  condensing,  154 

formative,  154 

rarefying,  154 
Otis's  urethrometer,  535 
Ozsena,  147 

Pain  in  bone-syphilis,  152 
Palmar  syphiloderm,  94 

diagnosis,  97 
Panaris,  156 

Pancreas,  syphilis  of,  167 
Papillitis,  193 
Papular   syphiloderm,  diagnosis,   91 

prognosis,  92 
Papule  chancre,  32 
dry,  scaling,  32 

umbilicated,  33 
Papules,  89 

dry,  90 

lenticular,  92 

miliary,  90 

moist,  98 
Papulo-squamous  syphiloderm,  93 
Paraphimosis,  318 

and  chancroid,  290 

reduction  of,  319 

symptoms,  318 

treatment,  319 
Parenchymatous  exostoses,  155 

iritis,  190 
Paronychia,  132 

syphilitica,  132 
Patches,  mucous,  98 
Pederasty,  334 

"  Pemphigus,  syphilitic,"  202 
Perineal  section,  562 
Periodicity  in  seminal  losses,  328 
Periostitis,  syphilitic,  treatment,  260 
Peripheral  nerves,  syphilis  of,  185 
Phagedena  and  chancroid,  291 
Pharynx  in  hereditary  syphilis,  213 

in  syphilis,  treatment,  258 

syphilis  of,  147 
Phimosis,  315 

and  chancroid,  290 
treatment,  309 

diagnosis,  316 

symptoms,   315 

treatment,  317 


Physical  examination  of  patients,  22 
Physician,  duty  of,  respecting  syph- 
ilis in  the  family,  271 
Physiology  of  generative  organs,  326 
Pigmentary  syphiloderm,  81 
Placenta,  syphilis  of,  200 
Plantar  syphiloderm,  94 
Plaque  muqueuse,  138 
Plaques,  mucous,  98 
Plaques  muqueuses,  98 
Pneumonia,  syphilitic,  164 
Pointed  wart,  100 
Pollutions,  329 
Polymorphism  in  syphilis,  75 
Posterior  urethritis,  397 
Pox,  25 
Precautions  required   by  physicians, 

18 
Precocious  syphilis,  59 
Pregnancy  in  syphilis,  treatment,  265 
Premature  ejaculation  of  semen,  332 
Primary  syphilis,  58 
Progressive  ossifying  myositis,  160 
Proliferating  syphilitic  rectitis,  172 
Prostatitis,  acute,  456 

abscess  in,  459 

causes,  456 

constitutional    disturbances     in, 

458 
diffuse,  457 
follicular,  457 
parenchymatous,  457 
treatment,  460 
chronic,  462 
follicular,  462 
parenchymatous,  463 
prognosis,  466 
symptoms,  462 
treatment,  465 
Prostatorrhcea,  462 
Prostitution  and  syphilis,  276 

regulation  of,  by  law,  276 
Pseudo-chancre  indure,  40 
Pseudo-gonorrhoea,  347 
Pseudo-paralysis  of  hereditary  syph- 
ilis, 211 
Psoriasis  linguae,  1 41 
of  genital  regions,  47 

diagnosis,  304 
syphilitic,  94 
Purpuric  syphiloderm,  87 
Pustular  lesions  in  hereditary  syph- 
ilis, 204 
syphiloderm,  diagnosis,  10S 
miliary,  103 
pathology,  109 
syphilodermata,  101 
Pustulo-crustaceous  syphiloderm,  106 


590  INDEX. 

Pustulo-ulcerative   syphiloderm,    106 
Pyelitis  from  gonorrhoea,  472 

diagnosis,  473 

symptoms,  473 

treatment,  474 

Radezyge,  25 

Rarefying  osteitis,  154 

Raw-ham  color,  75 

Rectal  stricture,  syphilitic,  treatment, 

260 
Rectite      proliferante      syphilitique, 

172 
Rectitis,  proliferating,  syphilitic,  172 
Rectum,  gummata  of,  169 
in  hereditary  syphilis,  217 
in  syphilis,  treatment,  260 
syphilis  of,  167 
Relapses  in  gonorrhoea,  357 
Relapsing  chancre,  40 
Resolutive   tubercular    syphiloderm, 

no 
Respiratory  tract,  syphilis  of,  146 
Retention  of  urine  due  to  stricture, 
568 
in  stricture,  519 
treatment,  383 
Retina,  syphilis  of,  192 

"  spots  of  exudation  "  in,  192 
Retinitis,  central  recurrent,  193 
Retrograde  catheterization,  568 
Rheumatism,  gonorrhoea!,  479 
Rhinitis,  syphilitic,  146 
Roseola  syphilitica,  83 
Rupia,  106 

"  Sabre-blade  deformity  "  in  he- 
reditary syphilis,  2IO 
Sadism,  334 

Safeguard  against  syphilis,  278 
Salivation,   241 
Sapphism,  334 
Satyriasis,  334 
Scabies  of  genital  region,  diagnosis, 

305 
Scale  for  urethral  instruments,  533 

American,  534 

English,  534 

French,  533 
Scaly  patches  of  mouth,  141 
Schanker,  28 
Schlei?)ijluss,  340 
Sciatica,  syphilitic,  186 
Sclerotic,  syphilis  of,  189 
Secondary  syphilis,  58 
Serpiginous  syphiloderm,  124 

diagnosis,  126 
Sexual  debility,  328 


Sexual   indulgence    after    infection, 

275 
after  syphilitic  infection,  274 

psychopathy,  334 

weakness,  331 
Sheath,  tendinous,  syphilis  of,  159 
Sifilide,  25 
Sifilis,  25 
Silver  catheters,  535 

spot,  33 
Simple  chancre,  279 
Situation  of  syphilodermata,  77 
Skin  in  syphilis,  73 
Smoker's  patches,  141 
"  Snuffles,"  206 
Society  and  syphilis,  271 
Soft  chancre,  34,  279 
Soluble   salts   of  mercury   for   injec- 
tion, 239 
Sounding  the  urethra,  526 
Sounds,  steel,  534 
Spermatic  cord,  syphilis  of,  173 
Spermatozoa  in  urine,  330 
Spizen  IVarzen,  99 
Spleen  in  hereditary  syphilis,  217 

syphilis  of,  70,  167 
Stages  of  syphilis,  57 
Stains  for  the  gonococcus,  342 
"  Stammering  of  bladder"    in  tabes, 

1 84 
Steel  and  flexible  instruments  com- 
pared, 539 

sounds,  534 
short,  534 
Stomach  in  hereditary  syphilis,  215 
Strapping  the  testicle,  method  of,  453 
Stricture,  annular,  507 

complications,  568 

constitutional  symptoms,  521 

continuous  dilation,  555 

definition,  507 

diagnosis,  542 

discharge,  518 

divulsion,  568 

duration  of  treatment,  552 

extravasation  in,  521,  574 

false  passage  in,  570 

filiform  bougies  in,  538 

fistula,  521 

frequency  of  sittings,  550 

gradual  dilation,  548 

irritable,  509 

linear,  507 

of  large  calibre,  508,  549 

of  small  calibre,  508,  553 

of  the  rectum,  syphilitic,  169 
treatment,  260 

of  the  urethra,  500 


INDEX. 


591 


Stricture  of  the  urethra,  changes  in 
bladder  and  kidneys,  471 
in  the  urethra,  514 
congenital,  504 
etiology,  510 
lesion  in,  513 
location,  510 
number,  509 
opening  in,  513 
organic,  507 
pathology,  512 
resilient,  509 
results,  516 
retention  in,  568 
sexual  disturbances,  520 
spasmodic,  501 
symptoms,  516 
time  required  for  development, 

5" 

tortuous,  507 

traumatic,  511 

urethral  fever  in,  571 

varieties,  507 
rapid  dilation,  568 
Suspensory  bandages,  376 
Syme's  operation,  562 
Symmetry  in  syphilodermata,  74 
Synonyms  of  syphilis,  25 
Syphilides,  73 

Syphilis,   accidents  and  injuries   in, 
72 
acquired,  25 

infantile,  270 
and  marriage,  273 
and  prostitution,  276 
and  tabes,  183 
atrophy  of  tongue  in,  144 
benignant,  60 
bones  in,  71 
cerebro-spinal,  184 
congenital,  196 
etiology,  25 

evolution  of,  in  stages,  57 
galloping,  59 
germ  of,  25 
glycosuria  in,  178 
hemiatrophy  of  tongue  in,  144 
hemorrhagic,  220 
hereditary,  196 

adrenals  in,  217 

anus  in,  217 

bones  in,  209 

bronchi  in,  214 

condylomata  in,  204 

cranial  bones  in,  218 

cutaneous  lesions  in,  202 

diagnosis,  202 

ear  in,  220 


Syphilis,  hereditary,  etiology,  196 

eye  in,  219 

furuncular  lesions  in,  204 

genital  organs  in,  208 

glands  in,  208 

hairs  in,  208 

intestinal  tract  in,  215 

larynx  in,  214 

liver  in,  216 

lungs  in, 215 

lymphatics  in,  208 

mucous  membranes  in,  205 

nails  in,  207 

nasal  passages  in,  212 

nervous  system  in,  217 

oesophagus  in,  215 

pathology,  200 

pharynx  in,  213 

pustular  lesion  in,  204 

rectum  in,  217 

"sabre-blade"  deformity  in,  2IO 

skin-lesions  in,  202 
bullous,  204 
hemorrhagic,  205 
macular,  203 
papular,  203 
tubercular,  205 

spleen  in,  217 

stomach  in,  215 

symptoms,  201 

teeth  in,  212 

trachea  in,  214 

treatment,  265 

inunctions  in,  269 

vesicular  syphilodermata  in,  205 
hygiene,  221 
inherited,  196 
in  relation  with  the  family,  271 

with  society,  271 
jaundice  in,  70,  166 
kidney  in,  70 
malignant,  61,  62 
of  bones,  152 

diagnosis,  155 

pathology,   154 
of  bony  walls  of  orbit,  194 
of  brain,  180 
of  bronchi,  151 
of  ciliary  body,  191 
of  cranial  meninges,  180 
of  crystalline  lens,  192 
of  ear,  195 
of  epididymis,  173 
of  eye,  186 
of  eyelids,  187 
of  gastro-intestinal  tract,  165 
of  kidney,  177 
of  labyrinth,  196 


592 


INDEX. 


Syphilis  of  liver,  165 

of  ocular  appendages,  1 86 

muscles,  194 
of  optic  nerve,  193 
of  placenta,  200 
of  retina,  192 

"spots  of  exudation  "  in,  192 
of  the  anus,  167 
of  the  aponeuroses,  159 
of  the  blood-vessels,  102 
of  the  bones,  treatment,  259 
of  the  bronchi,  151 
of  the  bursse,  158 
of  the  choroid,  191 
of  the  cord,  182 
of  the  ear,  treatment,  264 
of  the  eye,  treatment,  263 
of  the  fingers,  156 
of  the  genito-urinary  organs,  172 
in  men,  172 
in  women,  175 
of  the  heart,  160 
of  the  iris,  189 
of  the  joints,  1 57 

diagnosis,  158 

pathology,  157 
of  the  larynx,  148 

diagnosis,  150 

prognosis,  151 
of  the  lungs,  163 
of  the  meninges,  182 
of  the  mouth,  136 

treatment,  255 
of  the  muscles,  159 
of  the  nails,  treatment,  259 
of  the  nervous  system,  179 
of  the  nose,  treatment,  257 
of  the  pancreas,  167 
of  the  peripheral  nerves,  185 
of  the  pharynx,  147 

treatment,  258 
of  the  rectum,  167 
of  the  respiratory  tract,  146 
of  the  sclerotic,  189 
of  the  skin,  73 
of  the  spermatic  cord,  173 
of  the  spleen,  167 
of    the    tendons    and     tendinous 

sheaths,  159 
of  the  testes,  173 
of  the  third  generation,  199 
of  the  tongue,  136 
of  the  trachea,  151 
of  the  vagina,  176 
of  the  vitreous  humor,   1 92 
precocious,  59 
prophylaxis  of,  278 
spleen  in,  70 


Syphilis,  tardy,  59 

treatment,  221 
Syphilitic  adenopathy,  53 
diagnosis,  55 

affections  of  the  hair,  128 
of  the  nail,  132 

alopecia  with  structural  changes, 
130 
without       obvious        structural 
changes,  129 

aneurysm,  163 

bubo,  53,  303 
treatment,  56 

cachexia,  69 

chancre,  28 

dactylitis,  156 

erythema,  83 

exostoses,  155 

fever,  67 

lesions,  treatment,  250 

lupus,  81 

lymphangitis,  53 

mothers,  197 

onychauxis,  134 

panaris,  156 

papules,  89 

pemphigus,  202 

pneumonia,  164 

psoriasis,  81,  94 

roseola,  83 

sciatica,  186 

snuffles,  206 

stricture  of  rectum,  169 

tubercles,  110 

urethritis,  347 

"white  swelling,"  157 
Syphiloderm,  atrophic,  HO 

corneous,  96 

corymbiform,  93 

dry,  no 

gummatous,  1 18 

miliary,  pustular,  103 

"  non-ulcerative,"  no 

nummular,  93 

purpuric,  87 

pustulo-crustaceous,  105 

pustulo-ulcerative,  105 

resolutive  tubercular,  no 

serpiginous,  125 

tubercular,  1 10 

ulcerative  tubercular,  113 

vegetating,  127 
Syphiloderma,  73 

palmar,  94 

plantar,  94 
Syphilodermata.  characteristics  of,  74 

classification,  81 

general  features  of,  74 


INDEX. 


593 


Syphilodermata,  macular,  81 

"  marmoraceous,"  82 

pigmentary,  81 

pustular,  101 

vesicular,   in    hereditary   syphilis, 
205 
Syphilophobia,  334 

Tabes  and  syphilis,  183 

diagnosis,  183 
Table  of  diagnostic  distinctions  be- 
tween  chancroid,  chancre, 
etc.,  300 
Tardy  syphilis,  59 
Teeth  in  hereditary  syphilis,  212 
Tendons,  syphilis  of,  159 
Tertiary  syphilis,  58 
Tobacco,  222 

Tongue,  atrophy  of,  in  syphilis,  144 
hemiatrophy  of,  in  syphilis,  144 
syphilis  of,  136 
Trachea  in  hereditary  syphilis,  214 

syphilis  of,  151 
Treatment,  external,  225 
internal,  225 
of  chancroidal  bubo,  309 
of  chancroids  with  phimosis,  309 
of  complications  of  chancroid,  309 
of  hereditary  syphilis,  265 
of  nervous  syphilis,  262 
of  rectal  stricture  in  syphilis,  260 
of  rectum  in  syphilis,  261 
of  syphilis,  221 

during  pregnancy,  265 

"  expectant, '!  225 

"  interrupted,"  225 

of  the  bones,  259 

of  the  ear,  264 

of  the  nose,  257 

of  the  skin,  250 

systemic,  225 

time  for  beginning,  223 

required  for,  224 
"  tonic,"  225 
of  syphilitic  alopecia,  255 
epididymitis,  261 
iritis,  263 
lesions,  250 
of  viscera  in  syphilis,  260 
Tribadism,  334 
7 'ripper,  340 
Tripper faden,  413 
Tubercles,  syphilitic,  1 10 
Tubercular  syphiloderm,  no 
diagnosis,  115 
ulcerative  syphiloderm,  113 
Tuberculous  urethritis,  348 
Tunnelled  sounds  and  catheters,  537 

38 


Two-glass  method,  413 

test,  399 
Tympanum,  196 

Ulcerative      tubercular      syphilo- 
derm,  113 
Ulcer-chancre,  32 
Umbilicated  papule,  33 
Unrecognized  gonorrhoea,  352 
Unreiner  Fluss,  340 
Urethral  calibre,  547 

chancres,  36 

curve,  524 

fever,  571 

folliculitis,  474 

hygiene,  371 

instruments,  lubrication  of,  532 
Urethrectomy,  568 
Urethritis,  acute,  338 

causes  other  than    gonorrhceal, 

348 
etiology,  339 

treatment,    general     considera- 
tions, 368 
of  different  forms,  368 
chronic,  402 
diagnosis,  408 
etiology,  402 
infectiousness  of,  409 
localization  of  lesions,  41 1 
pathology,  407 
prognosis,  440 
symptoms,  405 
treatment,  424 
urine  in,  412 
complications,  442 
diagnostic  table,  365 
endoscope  in,  417 
hygiene,  371,  402,  425 
infectious,  340 
in  women,  517 
non-infectious,  348,  359,  365 
pathology,  360 
posterior  acute,  397 
diagnosis,  399 
etiology,  397 
symptoms,  397 
treatment,  400 
syphilitic,  347 
tuberculosa,  348 
urine  in,  412 

shreds,  color-test  for,  415 
two-glass  method,  413 
Urethrometer,  535 

Otis's,  535 
Urethrotome,  Civiale's,  559 
Maisonneuve's,   561 
Otis's,  561 


594 


INDEX. 


Urethrotomy,  Cock's  operation,  567 
combined    internal    and    external, 

565 
external,  562 

with  a  guide,  562 
without  a  guide,  566 
indications  for,  556 
internal,  558 
Syme's  operation,  562 
Wheelhouse's  operation,  566 
Urinary  fever,  571 

Urine    in    gonorrhoea,  copaiba  reac- 
tion, 378 
in  urethritis,  two-glass  test,  399 

Vagina,  syphilis  of,  176 

Vaginitis,  gonorrhceal,  577 

Vapor    for    the    nostrils   in   svphilis, 

258 
Vaporization  of  mercury,  236 
Vegetating  syphiloderm,  127 
Vegetations  with  chancroid,  290 
Venereal  warts,  44,  99,  321 

treatment,  323 
Verole,  25 


Verruca  acuminata,  44,  99 
Vesicular  syphilodermata   in  heredi- 
tary syphilis,  205 
Vesiculitis,  467 

symptoms,  467 

treatment,  468 
Veterans  of  syphilis,  274 
Virulenter  Bubo,  293 
Virus,  syphilitic,  26 
Virus-carriers,  27 

Viscera  in  syphilis,  treatment,  260 
Vitreous  humor,  syphilis  of,  192 
Vulvitis,  gonorrhceal,  578 

'•' Wart-curk,"  253 
Warts,  moist,  44,  99 

pointed,   100 

venereal,  44,  99,  321 
treatment,  323 
Weicher  Schanker,  279 
Wheelhouse's  operation,  566 
Wife,  infected,  272 
Wilkinson's  salve,  252 
Winternitz's  psychrophor,  534 


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on  Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex 
Hospital  Medical  School,  London,  Eng.  Vol.  I.  Genera/  Surgery. — 
Handsome  octavo,  947  pages,  with  458  beautiful  illustrations  and  9 
lithographic  plates.  Vol.  II.  Special  or  Regional  Surgery. — Handsome 
octavo,  1072  pages,  with  471  beautiful  illustrations  and  8  lithographic 
plates.  Sold  by  Subscription.  Prices  per  volume:  Cloth,  $5.00  net; 
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"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clini- 
cian and  the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satis- 
faction to  the  editors  as  it  is  a  gratification  to  the   conscientious  reader." — Annals  of  Surgery. 

"  This  is  a  work  which  comes  to  us  on  its  own  intrinsic  merits.  Of  the  latter  it  has  very 
many.  The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors 
is  equally  so.  What  is  especially  to  be  recommended  is  the  painstaking  endeavor  of  each 
writer  to  make  his  subject  clear  and  to  the  point.  To  this  end  particularly  is  the  technique 
of  operations  lucidly  described  in  all  necessary  detail.  And  withal  the  work  is  up  to  date  in 
a  very  remarkable  degree,  many  of  the  latest  operations  in  the  different  regional  parts  of  the 
body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work  from  which  the  reader 
may  not  learn  something  new." — Medical  Record,  New  York. 

Jackson's  Diseases  of  the  Eye. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D., 
Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic  and 
College  for  Graduates  in  Medicine.  i2mo  volume  of  535  pages,  with 
178  illustrations,  mostly  from  drawings  by  the  author.    Cloth,  $2.50  net. 

Keating's  Life  Insurance. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating,  M.  D., 
Fellow  of  the  College  of  Physicians  of  Philadelphia ;  Ex-President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages.     With  numerous  illustrations.     Cloth,  $2.00  net. 

Keen  on  the  Surgery  of  Typhoid  Fever. 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  By  Wm. 
W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S.  (Hon.),  Professor  of  the  Principles 
of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College,  Phila- 
delphia, etc.    Octavo  volume  of  386  pages,  illustrated.    Cloth,  $3.00  net. 

Keen's    Operation    Blank.      Second  Edition,  Revised  Form. 

An  Operation  Blank,  with  Lists  of  Instruments,  etc.,  Required  in  Vari- 
ous Operations.  Prepared  by  W.  W.  Keen,  M.  D.,  LL.  D.,  F.  R.  C.  S. 
(Hon.),  Professor  of  the  Principles  of  Surgery  and  of  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia.  Price  per  pad,  blanks  for  fifty 
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Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical 
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Levy,  Klemperer,  arid  Eshner's  Clinical  Bacteriology. 

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phia Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

Lockwood's  Practice  tf  Medicine.         »JS^aSS^i. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lockwood, 
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Boston. 

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Raymond's  Physiology.    '^JtSUSSfa**. 

A  Text-Book  of  Physiology.  By  Joseph  H.  Raymond,  A.  M.,  M.  D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital. 

Saling'er  and  Kalteyer's  Modern  Medicine. 

Modern  Medicine.  By  Julius  L.  Salinger,  M.  D.,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College ;  and  F.  J.  Kalteyer, 
M.  D.,  Assistant  Demonstrator  of  Clinical  Medicine,  Jefferson  Medical 
College.     Handsome  octavo,  801  pages,  illustrated.     Cloth,  $4.00  net. 

Saundby's  Renal  and  Urinary  Diseases. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby,  M.  D. 
Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and  of  the 
Royal  Medico-Chirurgical  Society ;  Professor  of  Medicine  in  Mason 
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Saunders'  Medical  Hand- Atlases. 

See  pages  16  and   17. 

Saunders1  Pocket  Medical  Formulary,  sixth  Edition,  Revised. 

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Stevens'  Practice  of  Medicine.     Fifth  Edition,  Revised. 

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Stewart's    Physiology.       Fourth  Edition,  Revised. 

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Stoney's  Materia  Medica  for  Nurses. 

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Van  Valzah  and  Nisbet's  Diseases  of  the  Stomach. 

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in  our  opinion,  bears  off  the  palm  at  present." — New  York  Medical  Record. 


1.  Essentials  of  Physiology.     By  Sidney  Budgett,  M.  D.     A  New  Work. 

2.  Essentials  of  Surgery.     By  Edward  Martin,  M.  D.     Seventh  edition,  revised,  with 

an  Appendix  and  a  chapter  on  Appendicitis. 

3.  Essentials  of  Anatomy.     By   Charles   B.    Nancrede,   M.  D.     Sixth   edition,  thor- 

oughly revised  and  enlarged. 

4.  Essentials  of  Medical  Chemistry,  Organic  and  Inorganic.     By  Lawrence  Wolff, 

M.  D.      Fifth  edition,  revised. 

5.  Essentials  of  Obstetrics.     By  W.  Easterly  Ashton,  M.D.    Fourth  edition,  revised 

and  enlarged. 

6.  Essentials  of  Pathology  and  Morbid  Anatomy.     By  F.  J.  Kalteyer,  M.  D.     In 

preparation. 

7.  Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription-Writing.    By  Henry 

Morris,  M.  D.     Fifth  edition,  revised. 

8.  9.    Essentials  of  Practice  of  Medicine.     By  Henry  Morris,  M.  D.     An  Appendix 

on  Urine  Examination.  By  Lawrence  Wolff,  M.  D.  Third  edition,  enlarged 
by  some  300  Essential  Formulae,  selected  from  eminent  authorities,  by  Wm.  M. 
Powell,  M.  D.     (Double  number,  $1.50  net.) 

10.  Essentials  of  Gynecology.     By  Edwin  B.  Cragin,  M.  D.     Fifth  edition,  revised. 

11.  Essentials  of  Diseases  of  the  Skin.     By  Henry  W.  Stelwagon,  M.  D.     Fourth 

edition,  revised  and  enlarged. 

12.  Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal    Diseases.     By  Edward 

Martin,  M.  D.     Second  edition,  revised  and  enlarged. 

13.  Essentials    of    Legal    Medicine,   Toxicology,   and    Hygiene.     This   volume   is   at 

present  out  of  print. 

14.  Essentials  of  Diseases  of  the  Eye.     By  Edward  Jackson,  M.  D.     Third  edition, 

revised  and  enlarged. 

15.  Essentials  of  Diseases  of  Children.    By  William  M.  Powell,  M.  D.    Third  edition. 

16.  Essentials    of    Examination    of    Urine.     By    Lawrence   Wolff,   M.  D.      Colored 

"  Vogel  Scale."     (75  cents  net.) 

17.  Essentials  of  Diagnosis.     By  S.   Solis-Cohen,  M.  D.,  and  A.   A.  Eshner,  M.D. 

Second  edition,  thoroughly  revised. 

18.  Essentials    of    Practice    of    Pharmacy.     By  Lucius   E.    Sayre.     Second   edition, 

revised  and  enlarged. 

19.  Essentials  of  Diseases  of  the  Nose  and  Throat.     By  E.  B.  Gleason,  M.  D.     Third 

edition,  revised  and  enlarged. 

20.  Essentials  of  Bacteriology.     By  M.  V.  Ball,  M.  D.     Fourth  edition,  revised. 

21.  Essentials  of  Nervous  Diseases  and  Insanity.     By  John  C.  Shaw,  M.  D.     Third 

edition,  revised. 

22.  Essentials  of   Medical   Physics.     By  Fred  J.  Brockway,  M.  D.     Second  edition, 

revised. 

23.  Essentials  of  Medical  Electricity.     By  David  D.  Stewart,  M.  D.,  and  Edward 

S.  Lawrance,  M.  D. 

24.  Essentials  of  Diseases  of  the  Ear.     By  E.  B.   Gleason,   M.  D.     Second   edition, 

revised  and  greatly  enlarged. 

25.  Essentials  of  Histology.     By  Louis  Leroy,  M.  D.     With  73  original  illustrations. 


Pamphlet  containing  specimen  pages,  etc.,  sent  free  upon  application. 

15 


Saunders'   Medical    Hand-Atlases. 

VOLUMES   NOW   READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
Diagnosis. 

By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner, 
M.  D.,  Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With 
179  colored  figures  on  68  plates,  64  text-illustrations,  259  pages  of  text. 
Cloth,  S3. 00  net. 

Atlas  of  Legal  Medicine. 

By  Dr.  E.  R.  vox  Hofmann,  of  Vienna.  Edited  by  Frederick 
Petersox,  M.  D.,  Chief  of  Clinic,  Nervous  Department,  College  of 
Physicians  and  Surgeons,  New  York.  With  120  colored  figures  on  56 
plates  and  193  beautiful  half-tone  illustrations.     Cloth,  §3. 50  net. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx. 

By  Dr.  L.  Gruxwald,  of  Munich.  Edited  by  Charles  P.  Grayson, 
M.  D.,  Physician -in-Charge,  Throat  and  Nose  Department,  Hospital  of 
the  University  of  Pennsylvania.  With  107  colored  figures  on  44  plates, 
25  text-illustrations,  and  103  pages  of  text.     Cloth,  $2.50  net. 

Atlas  and  Epitome  of  Operative  Surgery. 

By  Dr.  O.  Zuckerkaxdl,  of  Vienna.  Edited  by  J.  Chalmers 
DaCosta,  M.  D.,  Professor  of  Principles  of  Surgery  and  Clinical  Sur- 
gery, Jefferson  Medical  College,  Philadelphia.  With  24  colored  plates, 
217  text-illustrations,  and  395  pages  of  text.     Cloth,  $3.00  net. 

Atlas   and   Epitome   of    Syphilis    and  the   Venereal 
Diseases. 

By  Prof.  Dr.  Fraxz  Mracek,  of  Vienna.  Edited  by  L.  Bolton 
Baxgs,  M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  71  colored 
plates,  16  illustrations,  and  122   pages  of  text.      Cloth,  $3.50  net. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr.  O.  Haab,  of  Zurich.  Edited  by  G.  E.  de  Schweixitz,  M.  D., 
Professor  of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia. 
With  76  colored  illustrations  on  40  plates  and  228  pages  of  text. 
Cloth,  $3- 00  net. 

Atlas  and  Epitome  of  Skin  Diseases. 

By  Prof.  Dr.  Fraxz  Mracek,  of  Vienna.  Edited  by  Henry  W.  Stel- 
wagox,  M.  D.,  Clinical  Professor  of  Dermatology;  Jefferson  Medical 
College,  Philadelphia.  With  63  colored  plates,  39  half-tone  illustra- 
tions, and  200  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Special  Pathological  Histology. 

By  Dr.  H.  Durck,  of  Munich.  Edited  by  Ludwig  Hektoex  M.  D., 
Professor  of  Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts. 
Part  I.  Ready,  including  Circulatory,  Respiratory,  and  Gastro-intestinal 
Tract,  120  colored  figures  on  62  plates,  158  pages  of  text.  Part  II. 
Ready  Shortly.     Price  of  Part  I.,  $3. 00  net. 

16 


Saunders9  Medical   Hand-Atlases. 


VOLUMES   JUST   ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

By  Dr.  Ed.  Golebiewski,  of  Berlin.  Translated  and  edited  with  addi- 
tions by  Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Department 
of  Corrections  and  to  the  Almshouse  and  Incurable  Hospitals,  New- 
York.  With  40  colored  plates,  143  text-illustrations,  and  600  pages 
of  text.     Cloth,  $4.00  net. 

Atlas  and  Epitome  of  Gynecology. 

By  Dr.  O.  Shaeffer,  of  Heidelberg.  From  the  Second  Revised  Ger- 
man Edition.  Edited  by  Richard  C.  Norris,  A.M.,  M.  D.,  Gyne- 
cologist to  the  Methodist  Episcopal  and  the  Philadelphia  Hospitals ; 
Surgeon-in-Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored 
plates,  65  text-illustrations,  and  308  pages  of  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  the  Nervous  System  and  its 
Diseases. 

By  Professor  Dr.  Chr.  Jakob,  of  Erlangen.  From  the  Seco?id  Re- 
vised and  Enlarged  German  Edition.  Edited  by  Edward  D.  Fisher, 
M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  University  and 
Bellevue  Hospital  Medical  College,  New  York.  With  83  plates  and  a 
copious  text.     Cloth,  $3.50  net. 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Fifth  Revised  and 
Enlarged  German  Edition.  Edited  by  J.  Clifton  Edgar,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University 
Medical  School.      With  126  colored  illustrations.      Cloth,  $2.00  net. 

Atlas    and     Epitome    of     Obstetric     Diagnosis     and 
Treatment. 

By  Dr.  O.  Schaeffer,  of  Heidelberg.  From  the  Second  Revised  and  En- 
larged German  Edition.  Edited  by  J.  Clifton  Edgar,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School. 
72  colored  plates,  text-illustrations,  and  copious  text.      Cloth,  $3.00  net. 

Atlas   and   Epitome   of   Ophthalmoscopy  and    Oph- 
thalmoscopic   Diagnosis. 

By  Dr.  O.  Haab,  of  Zurich.  From  the  Third  Revised  and  Enlarged 
German  Edition.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor 
of  Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  152 
colored  figures  and  82  pages  of  text.      Cloth,  $3.00  net. 

Atlas  and  Epitome  of  Bacteriology. 

Including  a  Text-Book  of  Special  Bacteriologic  Diagnosis.  By  Prof. 
Dr.  K.  B.  Lehmann  and  Dr.  R.  O.  Neumann,  of  Wurzburg.  From  the 
Second  Revised  German  Edition.  Edited  by  George  H.  Weaver,  M.  D., 
Assistant  Professor  of  Pathology  and  Bacteriology,  Rush  Medical  College, 
Chicago.  Two  volumes  with  over  600  colored  lithographic  figures, 
numerous  text-illustrations,  and  500  pages  of  text. 


ADDITIONAL  VOLUMES   IN   PREPARATION. 

17 


NOTHNAGEL'S   ENCYCLOPEDIA 

OF 

PRACTICAL   MEDICINE 

Edited  by  ALFRED    STENGEL,  M.  D. 

-     Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania ;  Visiting 
Physician  to  the  Pennsylvania  Hospital 

IT  is  universally  acknowledged  that  the  Germans  lead  the  world  in  Internal 
Medicine  ;  and  of  all  the  German  works  on  this  subject,  Nothnagel's  "  Ency- 
clopedia of  Special  Pathology  and  Therapeutics"  is  conceded  by  scholars  to 
be  without  question  the  best  System  of  Medicine  in  existence.  So  necessary 
is  this  book  in  the  study  of  Internal  Medicine  that  it  comes  largely  to  this  country 
in  the  original  German.  In  view  of  these  facts,  Messrs.  W.  B.  Saunders  &  Com- 
pany have  arranged  with  the  publishers  to  issue  at  once  an  authorized  edition 
of  this  great  encyclopedia  of  medicine  in  English. 

For  the  present  a  set  of  some  ten  or  twelve  volumes,  representing  the  most 
practical  part  of  this  encyclopedia,  and  selected  with  especial  thought  of  the  needs 
of  the  practical  physician,  will  be  published.  The  volumes  will  contain  the  real 
essence  of  the  entire  work,  and  the  purchaser  will  therefore  obtain  at  less  than 
half  the  cost  the  cream  of  the  original.  Later  the  special  and  more  strictly 
scientific  volumes  will   be   offered  from  time  to  time. 

The  work  will  be  translated  by  men  possessing  thorough  knowledge  of  both 
English  and  German,  and  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  devoted.  It  will  thus  be  brought  thoroughly  up  to 
date,  and  the  American  edition  will  be  more  than  a  mere  translation  of  the  Ger- 
man ;  for,  in  addition  to  the  matter  contained  in  the  original,  it  will  represent  the 
very  latest  views  of  the  leading  American  specialists  in  the  various  departments 
of  Internal  Medicine.  The  whole  System  will  be  under  the  editorial  super- 
vision of  Dr.  Alfred  Stengel,  who  will  select  the  subjects  for  the  American  edition, 
and  will  choose  the  editors  of  the  different  volumes. 

Unlike  most  encyclopedias,  the  publication  of  this  work  will  not  be  extended 
over  a  number  of  years,  but  five  or  six  volumes  will  be  issued  during  the  coming 
year,  and  the  remainder  of  the  series  at  the  same  rate.  Moreover,  each  volume 
will  be  revised  to  the  date  of  its  publicatfon  by  the  American  editor.  This  will 
obviate  the  objection  that  has  heretofore  existed  to  systems  published  in  a  number 
of  volumes,  since  the  subscriber  will  receive  the  completed  work  while  the  earlier 
volumes  are  still  fresh. 

The  usual  method  of  publishers,  when  issuing  a  work  of  this  kind,  has  been 
to  compel  physicians  to  take  the  entire  System.  This  seems  to  us  in  many  cases 
to  be  undesirable.  Therefore,  in  purchasing  this  encyclopedia,  physicians  will  be 
given  the  opportunity  of  subscribing  for  the  entire  System  at  one  time ;  but  any 
single  volume  or  any  number  of  volumes  may  be  obtained  by  those  who  do  not 
desire  the  complete  series.  This  latter  method,  while  not  so  profitable  to  the  pub- 
lisher, offers  to  the  purchaser  many  advantages  which  will  be  appreciated  by  those 
who  do  not  care  to  subscribe  for  the  entire  work  at  one  time. 

This  American  edition  of  Nothnagel's  Encyclopedia  will,  without  question, 
form  the  greatest  System  of  Medicine  ever  produced,  and  the  publishers  feel  con- 
fident that  it  will  meet  with  general  favor  in  the  medical  profession. 


NOTHNAGEL'S  ENCYCLOPEDIA 

VOLUMES  JUST  ISSUED  AND  IN  PRESS 


VOLUME   I 
Editor,  William  Osier,  M.D.,  F.R.C.P. 

Professor  of  Medicine  in  Johns  Hopkins 
University 

CONTENTS 

Typhoid  Fever.  By  Dr.  H.  Curschmann, 
of  Leipsic.  Typhus  Fever,  By  Dr.  H. 
Curschmann,  of  Leipsic. 

Handsome  octavo  volume  of  about  600  pages. 
Just  Issued 


VOLUME  vn 
Editor,  John  H.  Musser,  M.  D. 

Professor  of  Clinical  Medicine,  University  of 
Pennsylvania 

CONTENTS 

Diseases  of  the  Bronchi.  By  Dr.  F.  A.  Hoff- 
mann, of  Leipsic.  Diseases  of  the  Pleura. 
By  Dr.  Rosenbach,  of  Berlin.  Pneumonia. 
By  Dr.  E.  Aufrecht,  of  Magdeburg. 


VOLUME  II 

Editor,  Sir  J.  "W.  Moore,  B.  A.,  M.D„ 
F.R.C.P.I.,  of  Dublin 

Professor  of  Practice  of  Medicine,  Royal  College 
of  Surgeons  in  Ireland 

CONTENTS 

Erysipelas  and  Erysipeloid.  By  Dr.  H.  Len- 
hartz,  of  Hamburg.  Cholera  Asiatica  and 
Cholera  Nostras.  By  Dr.  K.  von  Lieber- 
meister,  of  Tubingen.  "Whoocing  Cough 
and  Hay  Fever.  By  Dr.  G.  Sticker,  of 
Giessen.  Varicella.  By  Dr.  Th.  von  Jur- 
gensen,  of  Tubingen.  Variola  (including 
Vaccination).  Ey  Dr.  H.  Immermann,  of 
Basle. 

Handsome  octavo  volume  of  over  700  pages. 
Just  Issued 


VOLUME  VIII 
Editor,  Charles  G.  Stockton,  M.D. 

Professor  of  Medicine,  University  of  Buffalo 

CONTENTS 

Diseases  of  the  Stomach.    By  Dr.  F.  Riegel, 

of  Giessen. 


VOLUME  IX 
Editor,  Frederick  A.  Packard,  M.  D. 

Physician  to  the  Pennsylvania  Hospital  and  to  the 
Children' s  Hospital,  Philadelphia 

CONTENTS 

Diseases  of  the  Liver.   By  Drs.  H.  Quincke 
and  G.  Hoppe-Seyler,  of  Kiel. 


VOLUME  in 
Editor,  'William  P.  Northrup,  M.  D. 

Professor  of  Pediatrics ,  University  and  Bellevue 
Medical  College 

CONTENTS 

Measles.  By  Dr.  Th.  von  Jurgensen,  of 
Tubingen.  Scarlet  Fever*  By  the  same 
author.     Rotheln.    By  the  same  author. 


VOLUME  X 
Editor,  Reginald  H.  Fitz,  A.M.,  M.  D. 

Hersey  Professor  of  the  Theory  and  Practice 
of  Physic,  Harvard  University 

CONTENTS 
Diseases  of  the  Pancreas.     By  Dr.  L.  Oser, 
of  Vienna.     Diseases  of  the  Suprarenals. 
By  Dr.  E.  Neusser,  of  Vienna. 


VOLUME  VI 
Editor,  Alfred  Stengel,  M.D. 

Professor  of  Clinical  Medicine,  University  of 
Pennsylvania 

CONTENTS 

Anemia.  By  Dr.  P.  Ehrlich,  of  Frankfort  - 
on-the-Main,  and  Dr.  A.  Lazarus,  of  Char- 
lottenburg.  Chlorosis.  By  Dr.  K.  von 
Noorden,  of  Frankfort-on-the-Main.  Dis- 
eases of  the  Spleen  and  Hemorrhagic 
Diathesis.   By  Dr.  M.  Litten,  of  Berlin. 


VOLUMES  W,  V,  and  XI 
Editors  announced  later 

ol.  IV. — Influenza  and  Dengue.  By  Dr.  0. 
Leichtenstern,  of  Cologne.  MalarialDis- 
eases.    By  Dr.  J.  Mannaberg,  of  Vienna. 

°k  V- — Tuberculosis  and  Acute  General 
Miliary  Tuberculosis.  By  Dr.  G.  Cornet, 
of  Berlin. 

ol.  XI. — Diseases  of  the  Intestines  and 
Peritoneum.  By  Dr.  H.  Nothnagel, 
of  Vienna. 


x9 


CLASSIFIED   LIST 

OF  THE 

MEDICAL    PUBLICATI 


OF 


W.  B.  SAUNDERS  &  COMPANY 


ANATOMY,  EMBRYOLOGY, 

HISTOLOGY. 

Bblim,  Davidoff,  and  Huber — A  Text- 
Book  of  Histology 4 

Clarkson — A  Text-Book  of  Histology,  .    .  5 

Haynes — A  Manual  of  Anatomy 7 

Heisler — A  Text-Book  of  Embryology,  .    .  7 

Leroy — Essentials  of  Histology,  ....  15 

Nancrede — Essentials  of  Anatomy 15 

Nancrede — Essentials    of    Anatomy    and 

Manual  of  Practical  Dissection,  ....  10 

BACTERIOLOGY. 

Ball — Essentials  of  Bacteriology 15 

Frothingham — Laboratory  Guide 6 

Gorham — Laboratory  Course  in  Bacteri- 
ology   22 

Lehmann  and  Neumann — Atlas  of  Bacte- 
riology,     17 

Levy  and  Klemperer's  Clinical  Bacteri- 
ology,    9 

Mallory  and  Wright— Pathological  Tech- 
nique,    9 

McFarland — Pathogenic  Bacteria 9 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— Infant's  Weight  Chart 7 

Hart — Diet  in  Sickness  and  in  Health,  .    .  7 

Keen — Operation  Blank, 8 

Laine — Temperature  Chart 9 

Meigs — Feeding  in  Early  Infancy 10 

Starr — Diets  for  Infants'  and  Children,  .    .  12 

Thomas — Diet-Lists 13 

CHEMISTRY  AND  PHYSICS. 

Brockway — Essentials  of  Medical  Physics,  15 

Wolff — Essentials  of  Medical  Chemistry,  .  15 

CHILDREN. 
An  American  Text-Book  of  Diseases  of 

Children 1 

Griffith — Care  of  the  Baby 7 

Griffith— Infant's  Weight  Chart 7 

Meigs— Feeding  in  Early  Infancy 10 

Powell — Essentials  of  Diseases  of  Children,  15 

Starr— Diets  for  Infants  and  Children,  .    .  12 

DIAGNOSIS. 

Cohen  and  Eshner — Essentials  of  Diag- 
nosis   15 

Corwin — Physical  Diagnosis 5 

Vierordt — Medical  Diagnosis 14 

DICTIONARIES. 
The  American  Illustrated  Medical  Dic- 
tionary,     3 

The  American  Pocket  Medical  Dictionary,  3 

Morten — Nurses'  Dictionary, 10 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text-Book  of  Diseases  of 

the  Eye,  Ear,  Nose,  and  Throat 1 

De  Schweinitz — Diseases  of  the  Eye,    .    .  6 
Friedrich  and  Curtis — Rhinology,  Laryn- 
gology and  Otology, 6 

Gleason — Essentials  of  Diseases  of  the  Ear,  15 

Gleason — Ess.  of  Dis.  of  Nose  and  Throat,  15 

Gradle — Ear,  Nose,  and  Throat 22 

Griinwald   and    Grayson — Atlas  of  Dis- 
eases of  the  Larynx 16 

Haab  and  De  Schweinitz — Atlas  of  Exter- 
nal Diseases  of  the  Eye 16 

Haab  and  De  Schweinitz — Atlas  of  Oph- 
thalmoscopy   17 

Jackson — Manual  of  Diseases  of  the  Eye,  8 

Jackson — Essentials   of  Diseases  of  Eye,  15 

Kyle — Diseases  of  the  Nose  and  Throat,  .  9 

GENITO-URINARY. 

An  American  Text-Book  of  Genito-Uri- 

naryand  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 

Venereal  Diseases 8 

Martin — Essentials     of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,  ...  15 
Mracek  and  Bangs — Atlas  of  Syphilis  and 

the  Venereal  Diseases 16 

Saundby — Renal  and  Urinary  Diseases,  .   .  11 

Senn — Genito-Urinary  Tuberculosis,  ...  12 

Vecki — Sexual  Impotence 14 

GYNECOLOGY. 

American  Text-Book  of  Gynecology, 

Cragin — Essentials  of  Gynecology,  .    ...  15 

Garrigues — Diseases  of  Women 6 

Long — Syllabus  of  Gynecology, 9 

Penrose — Diseases  of  Women, . 
Pryor — Pelvic  Inflammations.  . 

Sohaeffer  &  Norris — Atlas  of  Gynecology,  17 

HYGIENE. 

Abbott — Hygiene  of  Transmissible  Diseases  3 

Bergey — Principles  of  Hygiene 22 

Pyle — Personal  Hygiene 11 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

American  Text-Book  of  Therapeutics,  .    .  1 
Butler — Text-Book    of    Materia    Medica, 

Therapeutics,  and  Pharmacology,    ...  4 

Morris — Ess.  of  M.  M.  and  Therapeutics,  15 

Saunders'  Pocket  Medical  Formulary,  .    .  11 

Sayre — Essentials  of  Pharmacy, 15 

Sollmann — Text- Book  of  Pharmacology,  .  22 

Stevens — Manual  of  Therapeutics,    ...  13 

Stoney — Materia  Medica  for  Nurses,    .    .  13 

Thornton — Prescription- Writing 13 


20 


MEDICAL  PUBLICATIONS  OF  W.  B.  SAUNDERS  6-  CO.    21 


MEDICAL  JURISPRUDENCE  AND 
TOXICOLOGY. 

Chapman — Medical  Jurisprudence  and 
Toxicology 5 

Golebiewski  and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents, 17 

Hofmann  and  Peterson — Atlas  of  Legal 
Medicine 16 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Brower — Manual  of  Insanity, 22 

Chapin — Compendium  of  Insanity,    ...  5 
Church  and  Peterson — Nervous  and  Men- 
tal Diseases 5 

Jakob  &  Fisher — Atlas  of  NervousSystem,  17 
Shaw — Essentials  of  Nervous  Diseases  and 

Insanity 15 

NURSING. 

Davis — Obstetric  and  Gynecologic  Nursing,  6 

Griffith— The  Care  of  the  Baby 7 

Hart — Diet  in  Sickness  and  in  Health,   .    .  7 
Meigs — Feeding  in  Early  Infancy,  .    . 
Morten — Nurses'  Dictionary,    .... 

Stoney — Materia  Medica  for  Nurses,      .    .  13 

Stoney — Practical  Points  in  Nursing,  ...  13 

Stoney — Surgical  Technic  for  Nurses,    .    .  13 

Watson — Handbook  for  Nurses 14 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,    .  2 

Ashton — Essentials  of  Obstetrics 15 

Boisliniere — Obstetric  Accidents 4 

Borland— Modern  Obstetrics 6 

Hirst — Text-Book  of  Obstetrics 7 

Norris — Syllabus  of  Obstetrics 10 

Schaeffer  and  Edgar — Atlas  of  Obstetri- 
cal Diagnosis  and  Treatment 17 

PATHOLOGY. 
An  American  Text-Book  of  Pathology,    .     2 
Durck  and  Hektoen — Atlas  of  Pathologic 

Histology 16 

Kalteyer — Essentials  of  Pathology,    ...    15 
Mallory  and  Wright — Pathological  Tech- 
nique,  9 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Stengel — Text-Book  of  Pathology,     ...    12 
Warren — Surgical  Pathology  and  Thera- 
peutics,    14 

PHYSIOLOGY. 

An  American  Text-Book  of  Physiology,  2 
Budgett — Essentials  of  Physiology,  ...  15 
Raymond — Text-Book  of  Physiology,  .  .  n 
Stewart—  Manual  of  Physiology,    ....    13 

PRACTICE  OF  MEDICINE. 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Anders — Practice  of    Medicine, 4 

Eichhorst — Practice  of  Medicine 6 

Lockwood — Manual    of    the    Practice    of 

Medicine 9 

Morris — Ess.  of  Practice  of  Medicine,  .    .    15 
Salinger  and  Kalteyer — Modern   Medi- 
cine  11 

Stevens — Manual  of  Practice  of  Medicine,    13 


SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases 2 

Hyde  and  Montgomery — Syphilis  and  the 
Venereal  Diseases, 8 

Martin —  Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,     .    .    15 

Mracek  and  Stelwagon — Atlas  of  Diseases 
of  the  Skin, 16 

Stelwagon — Essentials  of  Diseases  of  the 
Skin 15 

SURGERY. 

An  American  Text-Book  of  Surgery,  .  .  2 
An  American  Year-Book  of  Medicine  and 

Surgery 3 

Beck — Fractures 4 

Beck — Manual  of  Surgical  Asepsis,     ...  4 

Da  Costa — Manual  of  Surgery 5 

International  Text-Book  of  Surgery,  .    .  8 

Keen — Operation  Blank 8 

Keen — The   Surgical    Complications   and 

Sequels  of  Typhoid  Fever 8 

Macdonald — Surgical  Diagnosis  and  Treat- 
ment   9 

Martin —  Essentials    of    Minor    Surgery, 

Bandaging,  and  Venereal  Diseases,      .    .  15 

Martin— Essentials  of  Surgery 15 

Moore — Orthopedic  Surgery 10 

Nancrede — Principles  of  Surgery 10 

Pye — Bandaging  and  Surgical  Dressing,     .  11 

Scudder — Treatment  of  Fractures,     ...  12 

Senn — Genito-Urinary  Tuberculosis,  ...  12 

Senn — Practical  Surgery, 12 

Senn — Syllabus  of  Surgery 12 

Senn — Pathology  and  Surgical  Treatment 

of  Tumors 12 

Warren — Surgical  Pathology  and  Thera- 
peutics,     14 

Zuckerkandl  and   Da   Costa — Atlas    of 

Operative  Surgery 16 

URINE  AND  URINARY  DISEASES. 

Ogden — Clinical  Examination  of  the  Urine,    10 
Saundby — Renal  and  Urinary  Diseases,    .    11 
Wolff —  Handbook     of      Urine-Examina- 
tion,      22 

Wolff —  Essentials      of     Examination     of 
Urine, 15 

MISCELLANEOUS. 

Bastin — Laboratory  Exercises  in  Botany,  .     4 
Golebiewski  and  Bailey — Atlas  of  Dis- 
eases Caused  by  Accidents 17 

Gould  and  Pyle — Anomalies  and  Curiosi- 
ties of  Medicine 7 

Grafstrom — Massage, 7 

Keating — How  to  Examine  for  Life  Insur- 
ance       8 

Saunders'  Medical  Hand-Atlases,  .  .  16,17 
Saunders'  Pocket  Medical  Formulary,  .  .  11 
Saunders'  Question-Compends,  .  .  .  14,15 
Stewart    and    Lawrence — Essentials    of 

Medical  Electricity, 15 

Thornton— Dose-Book    and    Manual    of 

Prescription-Writing,      13 

Van  Valzah  and  Nisbet — Diseases  of  the 
Stomach 13 


THE  LATEST  BOOKS. 


Bergey's  Principles  of   Hygiene. 

The  Principles  of  Hygiene :  A  Practical  Manual  for  Students,. 
Physicians,  and  Health  Officers.  By  D.  H.  Bergey,  A.  M.,  M.  D., 
First  Assistant,  Laboratory  of  Hygiene,  University  of  Pennsyl- 
vania.    Handsome  octavo  volume  of  about  500  pages,  illustrated. 

Brower's  Manual  of  Insanity. 

A  Practical  Manual  of  Insanity.  By  Daniel  R.  Brower,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases,  Rush  Medical  College,. 
Chicago.      i2mo  volume  of  425  pages,  illustrated. 

Gorham's  Bacteriology. 

A  Laboratory  Course  in  Bacteriology.  By  F.  P.  Gorham,  M.  A.,. 
Assistant  Professor  in  Biology,  Brown  University.  i2mo  volume 
of  about  160  pages,  handsomely  illustrated. 

Gradle  on  the  Nose,  Throat,  and  Ear. 

Diseases  of  the  Nose,  Throat,  and  Ear.  By  Henry  Gradle,. 
M.  D.,  Professor  of  Ophthalmology  and  Otology,  Northwestern 
University  Medical  School,  Chicago.  Handsome  octavo  volume 
of  800  pages,  profusely  illustrated. 

Sollmann's  Pharmacology. 

A  Text-Book  of  Pharmacology.  By  Torald  Sollmann,  M.  D.r 
Lecturer  on  Pharmacology,  Western  Reserve  University,  Cleve- 
land, Ohio.      Royal  octavo  volume  of  about  700  pages. 

Wolfs  Examination  of  Urine. 

A  Handbook  of  Physiologic  Chemistry  and  Urine  Examination. 
By  Chas.  G.  L.  Wolf,  M.  D.,  Instructor  in  Physiologic  Chemistry, 
Cornell  University  Medical  College.  i2mo  volume  of  about  160 
pages. 


H99 
R0201 

1900 
Hyde 


o  1927 


